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J.  BYRON  SLOAN,  M.  D. 


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J.  BYRON  SLOAN,  M.  0. 


Digitized  by  the  Internet  Archive 
in  2016  with  funding  from 
Duke  University  Libraries 


https://archive.org/details/localanaesthetic1894manl 


LOCAL  ANESTHETICS 


AND 


Cocaine  Analg.esia; 


THOMAS  H.  MANLEY,  A.M.,  M.D., 


Member  of  New  York  Academy  of  Medicine;  The  New  York  Pathologi- 
cal Society;  The  American  Medical  Association;  The  New  York 
State  and  County  Associations  ; The  Metropolitan  Medical 
Society;  Vice-President  of  the  National  association  of 
Railway  Surgeons  ; Visiting  Surgeon  to  Harlem 
Hospital;  Consulting  Surgeon  to  Fordham 
Hospital,  and  Hospital  for  the 
Aged,  Yonkers. 


THEIR 


BY 


NEW  YORK, 


J.  H.  CHAMBERS  & CO., 


publishers  and  dealers  in  medical  BOOKS,  ST.  LOUIS. 
1894. 


IDIEIDIC^TIOIsr 


AS  A VERY  INADEQUATE  RECOGNITION  OF  FAVORS  BESTOWED  AND  MANY 
PRIVILEGES  ENJOYED, 

THIS  SHORT,' HURRIEDLY  WRITTEN  CONTRIBUTION 
IS  RESPECTFULLY  DEDICATED 
TO  THE 

NATIONAL  ASSOCIATION  of  RAILWAY  SURGEONS; 

WITH  THE  ARDENT  HOPE 

THAT  THROUGH  A FAITHFUL  AND  PERSEVERING  APPLICATION  OF  THE  PRINCIPLES 

HEREIN  EMBODIED, 

DIFFICULTIES  AND  DANGERS  IN  THE  PERFORMANCE  OF  MANY 

SURGICAL  OPERATIONS 

MAY  BE  MINIMIZED,  AND  THAT  CONSERVATISM  IN  TRAUMATISM  MAY  BE  CARRIED  TO 

ITS  FARTHEST  LIMITS. 


THE  A UTHOR . 


ENTERED  ACCORDING  TO  ACT  OF  CONGRESS,  BY 


J.  H.  CHAMBERS  & COMPANY. 


IN  THE  OFFICE  OF  THE  LIBRARIAN  OF  CONGRESS,  AT  WASHINGTON,  I).  C. 


PREFACE. 


This  age  in  which  we  live,  is  one  of  lightning  progress; 
old  ideas  are  cast  aside  and  new  ones  crowded  to  the  front. 

This,  indeed,  has  been  a century  of  rush  and  push,  and 
things  are  often  accepted  with  the  stamp  of  professional  ap- 
proval, before  they  have  been  even  fairly  inspected.  Very 
naturally  many  of  these  have  had  but  a very  ephemeral  exist- 
ence and  scarcely  see  light,  before  their  hollow  claims  are  ex- 
posed and  they  are  cast  aside. 

Again,  we  are  dazzled  by  an  array  of  new  principles  and 
dogmas,  which  are,  to  at  once,  unravel  all  the  intricacies  of 
diagnosis  in  disease,  and  render  its  subjugation  prompt  and 
simple. 

But,  in  a little  while,  the  piercing  lens  of  the  just,  scientific, 
and  impartial  critic  and  analyst  discovers  little,  but  a mere 
net-work  of  fallacies. 

Nevertheless,  history  must  concede  to  this  age,  that  in  scien- 
tific progress  and  in  improvement  it  has  had  no  equal;  and  that 
in  no  department  of  science  has  the  ratio  been  greater  than  in 
medicine  and  surgery. 

Ten  years  ago  the  virtues  of  erythroxolon  were  discovered 
as  an  inhibitor  of  the  pain-sense,  and  as  an  agent  of  great 
value  as  a local  analgaesic  in  surgical  operations. 

For  six  years,  I have  constantly  employed  it;  every  year 
in  more  and  more  cases. 

It  was  expected,  that  some  one  of  our  many  fluent, 
talented  writers  would,  before  this  late  date,  have  placed  on 
the  market  a work  which  would,  in  some  sort  of  a classified 


VI 


PREFACE. 


arrangement,  describe  the  cases  in  which  cocaine  could  be 
most  successfully  employed;  give  its  modus-operandi  and 
technique  of  application;  but  none  such  has  appeared,  or,  as  far 
as  can  be  learned,  is  yet  in  preparation.  For  the  purpose  of, 
at  least,  in  part,  filling  in  this  hiatus,  this  short  monograph  is 
submitted.  T.  H.  M. 

New  York,  Jan.  i,  1894. 


OOZSTTIIjTTTS. 


PART  ONE. 

CHAPTER  I. 

General  Considerations,  .....  9 

Innate  Dangers,  - - - - - - 13 

Mental  Shock,  • - - - - - 14 

Systemic  Conditions,  - - - - - 15 

Individual  Idiosyncrasy,  - - - - - 15 

CHAPTER  II. 

Local  Anesthetics  and  Analgesics,  - - - 17 

Local  Anesthetics,  - - - - - 18 

Analgesics  Locally  Applied,  ....  2o 

CHAPTER  III. 

The  Indications  and  Technique  for  Local  Anesthetics,  - 24 

Indications,  ......  24 

Mechanical  Anesthesia,  - - - - - 25 

Thermal  Anesthesia,  .....  26 

Illustrative  Cases,  - - - - 31 

Liberation  of  the  Joint,  - - - - - 32 

Elbow-Joint  Anchylosis,  .....  33 

CHAPTER  IV. 

Modus-Operandi  of  the  Thermal  Agents  in  Reducing  the 

Pain-Sense,  - - - - - - 37 

Brevity  of  Surface  or  Local  Anesthesia,  ...  39 


—VII— 


vm 


CONTENTS. 


CHAPTER  V. 

Details  of  Technique  in  Thermal-Anaesthesia  and  Appro- 
priate Cases,  ------  41 

Agitated  Water,  ------  41 

PART  TWO. 

CHAPTER  VI. 

Cocaine  Analgaesia,  - - - - - 44 

Cocaine,  - - ' - - - - - 46 

Difference  in  the  Degree  of  Susceptibility  and  Diversity  of 

Action,  ------  48 

Haemostatic  Properties  of  Cocaine,  ...  49 

CHAPTER  VII. 

Technique  of  Administration,  When  Topically  or  Subcu- 
taneously Employed,  as  an  Analgaesic,  in  Surgical  Op 
erations,  ------  50 

Topical  Application,  - 50 

Hypodermic  Use  of  Cocaine,  - - - - 51 

The  Individual,  - - - - - - 51 

Individual  Idiosyncrasies,  - - - - 52 

The  Medicament,  - - - - 53 

CHAPTER  VIII. 

Surgical  Operations  in  Which  Hypodermic  Cocainization 

May  be  Employed  with  Advantage,  - - - 61 

The  Advantages  Which  Cocaine  Hypodermication  Offer  in 

the  Manual  of  Surgical  Operations,  ...  65 


CONTENTS. 


IX 


CHAPTER  IX. 

Regional  and  Anatomical  Divisions  of  Operations  for 

Cocainization,  - - - - - 67 

Head,  .......  67 

Technique  of  Cocainization  in  Skull  Injuries,  - 68 

Illustrative  Cases,  .....  70 

CHAPTER  X. 

Pathological  Conditions  of  the  Skull  and  Brain,  in  Which 

Cocaine  Analgesia  is  Efficacious  in  Surgical  Operations,  74 

CHAPTER  XI. 

Local  Analgsesia  in  Haematomata,  Small  Neoplasms  of  the 
Scalp,  in  Suspected  Cranial-Practures  and  Brain 
Lesions,  - - - - - - 77 

Cocainization  in  Scalp  and  Skull  Injuries,  ...  81 

CHAPTER  XII. 

Local  Analgesics  in  the  Surgery  of  the  Face  and  its  Con 

necting  Organs,  - - - - - 82 

Operations  Within  the  Buccal  Cavity,  ...  87 

CHAPTER  XIII. 

Local  Analgesics  in  the  Cervical  Region,  - 94 

CHAPTER  XIV. 

The  Surgery  of  the  Anterior  and  Lateral  Aspects  of  the 

Neck,  -------  97 


X 


CONTENTS. 


CHAPTER  XV. 

Cocaine-Analgaesia  in  Adult  Tracheotomy,  - - 98 

Cocainization  in  Tracheotomy,  - - 105 

CHAPTER  XVI. 

Local  Analgaesics  in  the  Surgery  of  the  Upper  Extremities,  109 

Cocainization  in  the  Surgery  of  the  Extremities,  in 

Observations,  • - - 117 

CHAPTER  XVII. 

Local  Analgaesics  in  the  Surgery  of  the  Thorax,  - 118 

Operations  on  Mammary  Gland,  • • 123 

CHAPTER  XVIII. 

Cocainization  in  the  Surgery  of  the  Abdomen,  - 126 

Enumerations  of  the  Pathological  Conditions  in  Which  Co- 
cainization May  be  Utilized  with  Advantage,  From 
Above  Downwards,  - - 127 

CHAPTER  XIX. 

Cocainization  in  SupraPubic  Operations  on  the  Bladder,  131 

CHAPTER  XX. 

Cocainization  in  Kelotomy  for  Strangulated  Hernia,  and  in 
Operations  for  the  Radical  Cure  of  the  Non  Strangu 
lated  Varieties  of  Hernia,  - 133 

In  the  Surgery  of  the  Bladder,  ....  153 

Comments  on  Cocainization  in  Strangulation  Cases;  Espe- 
cially the  Thirteen  Cases  Reported,  ■ - - 157 


CONTENTS.  XI 

CHAPTER  XXI. 

Gocainization  in  Genito  Urinary  Surgery,  - ■ 157 

CHAPTER  XXII. 

Cocainization  in  Gynaecological  Surgery,  • - - 160 

CHAPTER  XXIII. 

Cocainization  in  the  Surgery  of  Ano-Rectal  Diseases,  162 

Cocainization  in  Surgery  of  Rectum,  - - - 163 

CHAPTER  XXIV. 

Cocainization  in  the  Surgery  of  the  Lower  Extremities,  - 168 

Cocainization  in  Tenotomies,  - 169 

Cocainization  in  the  Surgery  of  the  Foot,  • - - 169 

CHAPTER  XXV. 

Cocainization  in  Miscellaneous  Operations,  • - 172 

CHAPTER  XXVI. 

Mixed  Anaesthesia,  or  the  Employment  of  Pulmonary. 

Anaesthetics  as  an  Accessory  in  Local  Analgaesics,  - 175 


LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAESIA, 


OHE. 

CHAPTER  I. 

GENERAL  CONSIDERATIONS. 

We  all  must  agree,  that  the  discovery  of  the  anaesthetic 
power  of  ether  and  chloroform  was  one  of  the  very  greatest 
boons  ever  conferred  on  humanity.  Through  it,  surgery  has 
been  revolutionized,  the  operative  field  enormously  extended, 
and  the  sum  total  of  human  life,  greatly  lengthened.  While 
there  remains  some  difference  of  opinion  on  the  question,  as  to 
whether  ether  or  chloroform  shortens  life,  when  no  immediate 
complications  follow  their  inhalation,  everyone  will  admit,  that 
their  administration  is  always  attended  with  danger  to  life; 
and  that  many,  in  the  full  tide  of  health  and  vigor  never  survive 
their  use.  It  must  be  conceded  too,  that  there  are  many  con- 
ditions of  the  organs  in  which  pulmonary-anaesthetics  are 
given,  only  at  a great  risk;  as,  in  pulmonary,  cardiac  and  renal 
maladies.  There  can  be  no  question  also,  but,  chemically 


10  LOCAL  ANAESI HET1CS  AND  COCAINE  A N A LG  AC  SI  A . 


pure  anaesthetics  are  scarce,  the  greater  part  of  them  being 
diluted,  adulterated  or  have  undergone  such  changes,  as  to 
render  their  administration  unsatisfactory  or  unsafe. 

Therefore,  a person  about  to  undergo  a surgical  operation, 
under  an  ethereal  anaesthetic,  has  to  face  two  dangers: 

First,  that  innate  to  the  operation  itself,  and,  secondly, 
that  which  attends  pulmonary-anaesthesia.  That  this  latter,  is 
no  visionary  fear  or  phantom,  is  amply  attested  by  the  full  and 
valuable  report  of  the  Committee  of  the  British  Medical  Asso- 
ciation, appointed  in  1880,  to  investigate  the  entire  subject  of 
anaesthesia;  and  to  submit  their  conclusions,  when  prepared  to 
do  so.  The  principal  object  of  these  investigations  was  to  de- 
termine the  relative  safety,  of  ether  and  chloroform. 

In  the  progress  of  their  labors  the  Committee  canvassed 
the  entire  profession  of  Great  Britain,  and  unearthed  an  enor- 
mous mass  of  invaluable  information  on  the  subject,  which  they 
had  under  consideration.  The  aggregate  mortality,  it  appears, 
in  Great  Britain  and  Ireland  from  pulmonary  anaesthetics  is 
something  appalling  to  contemplate.  But,  there  is  no  reason 
to  believe  it  is  any  less  in  America.  In  this  country,  however, 
we  are  not  so  ready  to  publish  our  mortal  cases;  in  fact,  it  is 
very  rare  that  one’s  eye  meets  a case,  in  any  current,  medical 
journal.  Many  cases  have  come  to  my  knowledge  in  which 
the  patient  died  on  the  operating  table,  but  they  were  never 
published. 

In  my  own  practice,  fortune  has  favored  me,  as  I never 
had  but  one  patient  die  suddenly  on  the  table  under  chloroform 
anaesthesia;  and  this  case  has  been  fully  reported  (. Medical 
News,  June  12,  1889);  but,  unhappily,  with  very  many  who  left 
the  table  alive,  their  early  deaths  were  only  too  traceable  to 


GENERAL  CONSIDER  A TIONS. 


11 


the  lethal  action  of  the  anaesthetic.  Many  never  rallied  com- 
pletely. In  others,  cardiac  paralysis,  or  a total  cessation  of  re- 
nal action,  suddenly  snapped  the  vital  cord;  when,  instead  of 
entering  the  cause  of  death  as  due  to  ether  poisoning,  we  em- 
ployed the  euphemistic  terms  “heart  failure,”  or  “suppression 
of  the  urine.” 

A very  elaborate  and  valuable  report  has  been  submitted 
recently  by  the  London  Lancet' s Commission:  (“Report  of  the 
L^ancet  Commission,  Appointed  to  Investigate  the  Subject  of 
the  Administration  of  Chloroform,  and  other  Anaesthetics  from 
a Clinical  Standpoint,”  Lancet,  April  27,  May  6,  May  20  and 
June  17,  1893),  giving  in  full,  the  details  of  a large  number  of 
cases  in  which  death  followed,  either  directly,  or  was  remotely 
connected  with  pulmonary-anaesthetics.  Besides,  there  are 
included  several  others  in  which  alarming  symptoms  occurred, 
but,  the  patients  survived  them.  This  latter  report  is  highly 
valuable,  because  it  embodies  nearly  every  description  of  cases, 
traumatic  and  pathological,  in  both  sexes,  in  both  extremes  of 
age,  and  operations  at  all  seasons,  and  under  every  diversity  of 
circumstance;  there  being  included,  those  who  were  in  extremis, 
and  those  who  were  in  good,  general  condition  when  anaes- 
thesia was  commenced. 

What  strikes  the  reader,  as  most  remarkable,  in  examining 
this  report,  is  the  number  of  deaths  from  ether.  Everyone  is 
aware  that  chloroform  is  a treacherous  and  dangerous  agent, 
in  the  hands  of  the  most  cautious  and  experienced;  though  few 
of  us,  in  America,  at  any  rate,  supposed  that  sulpheric-ether 
possessed  such  lethal  powers.  It  appeared  to  make  no  differ- 
ence as  to  how  the  anaesthetic  was  administered,  whether  by 
the  “open  method”  or  the  closed  inhaler,  for  none  were  abso- 


12  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

lutely  to  be  relied  on,  as  certain  preventatives,  against  grave 
symptoms.  The  number  of  accidents  was  large  in  hernial 
operations,  and  operations  on  the  rectum.  Many  succumbed, 
when  narcosis  was  induced,  for  simple  incisions,  into  the  bones 
and  joints.  There  were  55  cases  of  death  from  ether  collected. 
The  number  was  greater  in  the  male  than  in  the  female.  The 
average  age,  at  time  of  death,  in  the  male  was  46,  and  in  the 
female  40.  In  many  fatal  cases,  the  “A.  C.  E.”  or  1.  2.  3. 
mixture,  was  administered.  In  many,  of  the  chloroform  cases, 
when  toxic  symptoms  set  in,  ether  was  substituted.  Untoward 
accidents  occured  under  methylene;  and  bromide  of  ethyl  and 
ethedene  dichloride  are  set  down  as  responsible  for  five  deaths; 
the  former  for  three,  and  the  latter  for  two.  The  ether  and 
chloroform  mixture,  seems  to  have  been  equally  unsafe;  as  sev- 
eral deaths  are  chronicled  to  have  followed  its  employment. 
Death  had  followed  the  use  of  nitrous-oxide  and  ether.  It  ap- 
pears from  Juillards  figures  ( Journal  de  Medicine  de  Bordeaux, 
Dec.  12,  1892,  p.  217)  that  the  deaths  from  ether  are  about 
one  in  15,000,  and  one  in  3,300  from  chloroform. 

Unfortunately,  after  all  the  laborious  efforts  of  this  Commis- 
sion, it  was  unable  to  point  out  any  certain  and  effective  meas- 
ures for  resuscitation;  because,  as  it  says,  “the  same  measures 
adopted  in  the  ‘favorable  cases’  had  been  followed  out  in  those 
that  were  fatal.”  The  report  concludes  by  saying;  that,  “it  has 
been  found  impossible  to  deal  with  the  various  materials  used 
in  the  production  of  local  anaesthesia;  and,  although  there  have 
been  numerous  reports  of  deaths  under  cocaine,  they  have,  for 
the  above  reason,  been  omitted.”  This  latter  admission  is  very 
unfortunate;  though,  certainly  the  consideration  of  local  anaes- 
thetics was  beyond  the  scope  of  the  Commission’s  duties,  yet 


GENERAL  CONSIDERATIONS. 


13 


it  would  have  been  of  great  value,  now  that  cocaine  is  on  its 
trial,  and  promises,  at  an  early  day,  to  very  largely  displace 
the  pulmonary-anaesthetics,  in  many  cases,  for  which,  hereto- 
fore they  alone,  were  employed. 

A rather  extended  notice  of  this  report  has  been  made 
here,  though  it  may  seem  foreign  to  the  subject;  but,  as  it  again 
so  lucidly  and  so  fully  recalls  to  mind  the  dangers  which  always 
attend  chloroform  or  ether  toxaemia,  it  was  deemed  proper  to 
insert  a few  of  the  salient  points,  which  it  embodies.  Pulmon- 
ary anaesthetics  directly  kill,  through  the  circulatory  and  respi- 
ratory organs;  the  patient  ceases  to  breath  or  the  heart  sud- 
denly stops.  Now,  there  are  four  things  which  are  powerful 
accessories  in  bringing  about  a mortal  termination  under  pul- 
monary anaesthesia:  First,  the  inherent  dangers  in  the  opera- 

tion itself,  as,  through  haemorrhage  and  shock.  Secondly,  the 
psychological  element;  fear  and  apprehension.  Thirdly,  con- 
stitutional disease,  organic  changes.  Fourthly,  idiosyncrocies, 
and  morbid  susceptibilities. 

Innate  Dangers. 

Every  Surgeon  of  experience,  well  knows,  that  it  is  impos- 
sible to  prophesy,  how  an  operation  will  end,  for  the  reason 
that  some  subjects  bear  every  sort  of  surgical  manipulation 
very  badly;  besides,  because,  there  are  inherent  dangers,  in 
operations  on  certain  organs  or  regions  of  the  body.  We  are 
familiar  with  the  mortal  reflex  phenomena  which  at  times  at- 
tend the  dilation  of  the  anal  sphyncter,  the  passage  of  a sound 
into  the  bladder,  or  an  incision  on  any  of  the  anterior  thoracic 
areas.  An  anaesthetic  may  diminish  those  dangers,  but  it  will 
not  entirely  obviate  them. 


14  LOCAL  AN  AES  THE  TICS  AND  COCAINE  ANALGESIA. 


Mental  Shock. 

The  effects  of  mental  shock,  fright  and  dread,  are  only 
too  well  known,  to  require  special  reference  to  them  now. 
Many  in  the  ranks,  for  the  first  time  before  a battery  of  artill- 
ary are  mortally  palsied  at  its  first  volley.  Military  surgery 
abounds  in  the  records  of  such  cases. 

A most  trivial,  surgical  operation  will  often  induce  syn- 
cope; and,  when  this  does  not  occur,  the  effects  on  the  heart 
and  circulation  are  apparent.  How  many  times  have  we 
opened  the  veins  of  the  fore-arm,  for  a phebotomy,  only  to 
find  them  empty  of  blood?  And,  hence,  why  the  experienced, 
will  make  no  show  of  preparation  and  quickly  divides  the  ves- 
sels, while  he  diverts  his  patients  attention.  An  arm  may  be 
torn  off  at  the  trunk;  but,  for  the  moment  the  vessels  of  the 
horror-stricken  patient,  at  their  proximal  ends,  are  empty,  and 
lose  no  blood. 

Not  a few,  have  a presentiment  that  they  will  not  recover. 
They  are  wanting  in  hope,  depressed  and  despondent.  Dr. 
Charles  A.  Budd  used  to  relate  to  the  class,  at  the  University 
Medical-College  in  New  York,  in  his  obstetric  lectures,  the 
case  of  a young  lady,  about  to  be  confined;  who  had  a dream, 
that  she  would  flood  to  death  on  delivery.  He  acknowledged 
that  it  gave  him  serious  concern,  for  to  do  what  he  might,  he 
could  not  dissuade  her,  of  her  presentiment.  The  time  for 
accouchement  finally  arrived.  He  delivered  her  safely;  but  a 
mortal  flooding  set  in  at  once,  and  she  soon  sank;  as,  she  had 
predicted  she  would. 


GENERAL  CONSIDERATIONS. 


15 


Systemic  Conditions. 

The  vast  majority  of  our  patients,  on  whom  we  perform 
operations  for  pathological  conditions,  are  of  unsound  con- 
stitution. Many  are  passed  the  meridian  of  life;  when,  degen- 
erative changes  have  commenced  in  the  organs,  or  in  the 
blood  vessels. 

The  emunctory  organs  are  defective  in  the  work  of  elimi- 
nation. There  is  a marked  diminution,  in  the  function  of  tissue 
metabolism,  and  the  super-saturated  tissues  fail  to  throw  off 
the  excess  of  ethereal  fluid,  accumulated  in  them.  A tubercu- 
lous or  emphysematous  lung,  imperfectly  eliminates  the  volatile 
elements  with  which  its  interstitial  tissues  are  charged,  or  may 
cease  to  expand  altogether.  Ether  plays  havoc,  with  defective 
renal  organs.  In  cardiac  maladies,  we  always  give  ether  or 
chloroform,  with  trepidation  and  apprehension.  Our  patient 
under  these  conditions,  may  suddenly  blanche  or  go  into  a 
mortal  syncope,  with  the  first  few  whiffs  of  chloroform;  and  after 
ether,  pneumonic  symptoms  may  follow,  the  cold,  chilled  in- 
halations; renal  secretion  may  suddenly  cease,  when  we  will 
have  suppression  of  the  urine. 


Individual  Idiosyncracy. 

It  is  notorious  that  infants  and  children,  proportionally, 
require  a much  larger  quantity  of  an  anaesthetic  agent,  and 
come  out  from  under  its  influence  more  quickly  than  adults. 
We  will  sometimes  meet  cases,  in  the  adult,  in  which,  it  is 
quite  impossible  to  induce  the  full  anaesthetic  coma  of  ether 


16  LOCAL  ANAESTHETICS  AND  COCAINE  AN  A LG  AES  I A. 


or  chloroform,  without  giving  great  quantities;  or,  inducing 
grave  cerebral  or  pulmonary  symptoms.  Violent  vomiting  at 
once  commences,  tetanic  spasms  seize  the  whole  muscular  sys- 
tem, deep  cyanosis  sets  in  early,  with  irregular  striduluos 
breathing.  May  not  individual  peculiarity,  or  a positive 
idiosyncracy  in  a large  part,  account  for  many  of  those  sudden 
deaths  under  chloroform  anaesthesia?  It  is  perfectly  rational 
to  assume  that  ether  will  play  the  same  role  in  certain  indi- 
viduals. A medium  dose  of  opium  has  often  induced  mortal 
narcosis.  Strychnia,  arsenic  and  any  one  of  the  powerful 
agents  employed  in  pharmacy,  in  moderate  doses,  occasionally 
give  rise  to  grave  symptoms. 


CHAPTER  II. 


LOCAL  ANAESTHETICS  AND  ANALGESICS. 


It  is  therefore,  evident,  that  while  pulmonary-anaesthetics 
are  an  inestimable  boon  to  humanity,  their  administration  is 
fraught  with  danger;  immediate  and  remote;  that,  that  state  of 
suspended  animation  or  cerebration,  of  total  inhibition  of  the 
senses  and  the  sensory  nerves  cannot  be  induced,  with  impu- 
nity; but,  that  as  Dr.  Sigismund  Waterman,  of  New  York,  so 
clearly  pointed  out,  in  his  exhaustive  and  analytical  studies 
with  the  spectroscope,  (“A  Spectroscoptical  Study  and  Critical 
Analyses  of  the  Morphological  Elements  of  the  Blood  in  Those 
who  have  Submitted  to  the  Full- Anaesthesia  of  Chloroform, 
Ether  or  Nitrous-Oxide,”  p.  1 1 7),  the  blood  undergoes  the 
most  radical  changes  after  the  absorption  of  an  anesthetic. 
The  red  corpuscles  are  diminished  in  number  and  size;  their 
investing  capsule  is  shrunken  and  irregular  in  shape;  they  dis- 
integrate and  clog  the  capillaries,  and  a favorite  seat  for  their 
residue,  he  found,  was  in  the  parenchymatous  elements  of  the 
viscera;  particularly  the  brain  and  kidney. 

On  contrasting  the  chemical  composition  of  the  blood, 
before  and  after  anaesthesia,  Waterman  found  it  profoundly 
altered.  He  gives,  in  extenso , a large  number  of  cases,  which 
had  come  under  his  observation,  wherein  the  remote  con- 


—17— 


18  LOCAL  AN  AES  THE  TICS  AND  COCAINE  ANALGEESIA. 


sequences  of  anaesthetics  were  most  disastrous.  Nitrous-oxide, 
he  found,  was  particularly  baneful  in  the  female  sex. 

From  the  foregoing,  it  is  clearly  evident,  that  in  the  past 
we  have  been  altogether  too  indiscriminate  and  reckless  in 
the  use  of  anaesthetics.  But,  in  order  to  escape  dangers,  we 
must  avoid  their  occasion  as  far  as  possible;  wherefore,  if  we 
would  reduce  the  drawbacks  of  anaesthetics  to  a minimum;  two 
things,  in  particular,  are  imperative. 

First,  we  should  decline  to  employ  pulmonary  anaes- 
thetics in  all  trivial,  or  brief  operations. 

Secondly,  we  should  cast  about  us  for  some  agent  or 
substitute  which,  in  a large  measure,  may  replace  them.  For 
the  purpose  of  accomplishing  this  latter  object,  at  least,  in  a 
certain  measure,  our  present  labors  are  undertaken. 


Local  Anaesthetics. 

Since  the  very  earliest  times,  various  means  have  been 
in  vogue  for  effecting  local-anaesthesia.  The  limb  has  been 
tightly  compressed  above  the  site  of  operation.  Different 
liquids  and  medicated  effusions  have  been  employed.  The 
parts  have  been  chilled  with  ice;  and  later,  partly  frozen  with 
the  ether  spray.  It  is  claimed  that  the  parts  in  certain  impres- 
sionable individuals  may  be  rendered  senseless  by  hypnotic 
suggestion,  electricity,  etc.  In  pre-anaesthetic  days  it  was  ad- 
vised for  wounds  in  battle,  and  traumatisms  in  general,  that 
they  be  operated  on,  as  soon  after  their  infliction  as  possible, 
while  they  were  yet  numb;  and,  before  the  onset  of  inflam- 
mation. 


LOCAL  ANAESTHETICS  AND  ANALGESICS. 


19 


Local  anaesthetics  were  never  satisfactory.  This  was,  be- 
cause, to  secure  any  degree  of  success  at  all,  required  more 
than  ordinary  skill  and  judgment,  and  for  the  reason  that  in 
order  to  deaden  the  parts  to  feeling,  dangerous  freezing  of  the 
tissues,  in  careless  hands,  frequently  occurred.  Another 
cogent  objection  to  them,  was,  that  the  pain  which  their  appli- 
cation entailed,  might  be  greater,  than  that  inflicted  in  opera- 
ting. No  one  ever  ventured  their  employment  on  inflammed 
parts;  if  we  accept  a furuncle. 

When  we  bear  in  mind,  the  cardinal  distincion  between 
a local  anaesthetic  and  an  analgaesic,  we  can  the  better 
appreciate  the  harmful  consequences  which  may  follow  the 
former.  A local  anaesthetic  of  an  intense  frigorific  character 
produces  chemical  changes,  and  temporarily  destroys  all 
sense.  But  an  analgaesic  only  effects  the  pain-sense,  and  in  no 
manner  induces  chemical  changes,  or  endangers  the  vitality  of 
the  tissues. 

A temporary  asphyxiation  of  the  distal  parts  of  a limb,  by 
an  elastic  bandage,  effects  a diminution  of  sensation,  by  retard- 
ing all  metabolic  processes  and  diffusing  through  the  tissues 
imprisoned  carbon.  Refrigorant  processes  are  essentially 
those  of  dissolution;  which,  though,  when  arrested  at  the  right 
time,  effect  no  serious  detriment  to  the  cellular  elements. 
Parts  may  be  suddenly  chilled,  or  even  frozen  through,  when 
proper  precaution  is  observed,  without  permanent  organic 
change  succeeding.  The  former  is  a simple  and  safe  procedure. 
Its  mode  of  action,  is,  by  producing  a local  shock  to  the  parts; 
the  terminal  filaments  of  the  sensory  nerves  are  momentarily 
benumbed,  and.  there  is  a prompt  contraction  of  all  the  periph- 
eral vessels  and  capillaries,  so  that  immediately  on  incision 


20  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGALSIA. 


there  is  a noticeable  hemostasis,  when  the  incision  is  not 
carried  deeper  than  the  integument. 

When  it  is  intended  to  carry  anaesthesia  into  all  the  parts 
en  masse , and  totally  destroy  sensation,  then,  some  powerful 
frigorific  must  be  employed,  To  effect  this,  however,  in  itself, 
is  a very  painful  proceeding  and  not  only  that,  but  dangerous 
to  the  vitality  of  the  tissues.  For  this  purpose,  a mixture  of 
common  salt  and  broken  ice  has  been  employed,  and,  some- 
times ice  alone.  Of  late  years  the  ether  spray  has  been  uti- 
lized. When  frigorific  agents  are  utilized,  the  skin  is  whitened, 
stiff  and  brittle.  The  blood  is  all  driven  from  the  surface  into 
the  deeper  parts;  the  aqueous  elements  in  the  tissues  become 
congealed,  and  all  the  structures  solidify,  in  one  homogenous 
mass.  So  that,  except,  for  the  purpose  of  making  a puncture 
or  incision  painlessly,  this  species  of  anaesthesia  has  a very 
limited  application.  In  many  on  whom  it  has  been  injudici- 
ously employed,  uleration  or  gangrene  has  followed.  In  any 
event,  it  is  clear  that  through  it  were  devoid  of  any  mishaps, 
as,  a delicate  isolation  and  dissection  of  the  parts  are  quite 
impossible,  when  all  the  animal  fluids  are  solidified,  in  many 
surface  operations,  it  has  no  place  at  all. 


Analgesics  Locally  Applied. 

During  the  past  decade  the  pharmacological  chemist, 
through  synthetical  processes  and  experimentation  with  coal- 
tar  products  has  been  prolific  in  providing  the  profession  with 
internal  analgaesics.  Carl  Roller,  in  1880,  accidently  discovered 
the  local  analgaeesic  properties  of  the  hydrochlorate  of  co- 


LOCAL  AN  AES  THE  TICS  AND  ANALGESICS. 


21 


caine.  He  discovered,  that  it  acted  with  great  energy  on 
mucous  membranes;  notabley,  on  the  conjunctiva,  the  mem- 
brane of  Schneider,  and  in  the  buccal-cavity.  It  was  observed 
too,  at  the  same  time,  that  it  was  a haemostatic  agent  of  great 
power. 

its  action  is  very  feeble,  if  any,  on  the  unbroken  integ- 
ument. It  acts  with  varying  power  on  the  mucous  membrane, 
of  the  various  passages.  Cocaine  applied  on  the  surface,  or 
subcutaneously,  produces  no  chemical  changes,  but  spends  its 
energy,  wholly  on  the  sensory  nerves,  and  the  vaso-motor  fila- 
ments. It  paralyses  the  pain  sense  and  vascular,  nerve-sup- 
ply and,  hence,  is  an  analgaesic  and  haemostatic. 

On  incision  of  the  tissues,  the  patient  feels  the  blade 
divide  the  parts,  but  has  no  dolerous  sentation  accompany- 
ing it. 

Dr.  Corning,  of  New  York,  has  devised  a means,  by  which 
the  analgaesic  action  of  the  drug,  when  subcutaneously  injected 
into  a limb,  may  be  protracted.  He  confines  the  venous  cir- 
culation, by  an  elastic  bandage  applied,  above  the  point,  on  the 
limb,  at  which  an  operation  is  to  be  performed.  The  analgaesic 
power  of  cocaine  remains  about  thirty  minutes,  in  some  slightly 
a shorter  period,  in  others  somewhat  longer.  Except,  when 
applied  on  mucous  membranes,  or  open  wounds,  ulcers  or  sores, 
cocaine,  locally  administered  is  a somewhat  painful  procedure. 
Many  deep  punctures  of  the  hypodermic  needle  are  at  times 
necessary.  There  is  a possibility  of  infecting  healthy  tissues 
by  impure  solutions  or  unclean  instruments. 

In  all  cases  of  cocaine  analgcesia,  by  hypodermication,  more 
or  less  of  the  medicament  is  taken  up  by  the  general  circulation; 
and  therefore , in  certain  degrees , its  action  is  simultaneously , both 


22  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAESIA. 

local  and  constitutional.  Clinically,  at  least,  the  action  of  co- 
caine is  very  closely  allied  to  morphine  It  is  moderately 
narcotic,  is  exhilerating  in  its  effects;  it  strengthens  the  heart’s 
action,  and  begets  a state  of  quiet,  mental  repose.  Therefore, 
why  so  many  are  the  abject-slaves  of  the  “cocaine  habit;”  and 
in  no  calling,  it  seems,  to  a greater  extent,  than  among  mem- 
bers of  the  medical  profession. 

There  are  many  other  substances,  besides  cocaine,  which 
possess  analgaesic  properties.  Pure  water,  alchohol,  oleagin- 
ous substances,  solution  of  thermol,  camphor  and  antipyrine, 
and  other  chemical  agents,  induce  more  or  less  numbness  in 
the  tissues  after  hypodermic  injection.  None  of  them,  how- 
ever, are  of  any  practical  value,  for  the  reason,  that  they  irri- 
tate too  much;  or,  are  too  transient  in  their  effects. 

Cocaine,  in  the  largest  measure  of  any  medicinal  agent 
known,  fulfills  the  demands  of  a local  analgaesic.  But,  like  all 
other  valuable  agents  known,  its  administration  must  not  be 
indiscriminate,  nor  employed  without  studying  our  cases,  and 
providing  ample  safe-guards  against  failure  or  accident.  Its 
lethal,  toxic  action,  in  certain  individuals  and  its  utter  failure 
to  act  in  others,  are  the  most  serious  objections  against  this 
potent  agent.  It  is  well,  that  both  sides  should  be  candidly 
and  unqualifiedly  presented,  in  dealing  with  a question  of  such 
vital  importance  as  this. 

Our  antiseptics  have  enormously  enlarged  the  operative- 
field.  If  we  can  render  operative  intervention,  painless  and 
safe  without  pulmonary  anaesthetics,  it  is  plainly  our  duty  to 
endeavor  to  accomplish  this  end.  But,  in  so  doing,  we  must 
avoid  the  intemperate  zeal  of  the  enthusiast,  whose  high 
coloring  and  unqualified  vaunting  of  certain  therapeutic  agents 


LOCAL  ANESTHETICS  AND  ANALGESICS. 


23 


and  surgical  procedures  have  often  deluded  the  unwary,  into 
the  commission  of  serious  errors;  and  besides,  has  made  the 
prudent  and  circumspect  to  look  with  suspicious  and  doubt,  on 
many  really  valuable  modern  acquisitions,  which  well  merit  an 
intelligent  trial. 


CHAPTER  III. 


THE  INDICATIONS  AND  TECHNIQUE  FOR 
LOCAL  ANAESTHETICS. 

Indications. 

These  may  divided  into  two  classes;  first,  those  in  which 
there  are  good  and  substantial  reasons  for  declining  to  ad- 
minister, by  the  respiratory  organs,  or  subcutaneously,  a chem- 
ical anaesthetic  or  analgesic  of  any  description.  Such  cases 
are  unusual.  Secondly,  those  in  which  the  operative  inter- 
vention will  occupy  but  a moment;  as  when  the  parts  to  deal 
with,  lie  near  the  surface;  when  apparatuses  or  assistance  are 
not  within  reach,  to  administer  other  agents. 

Should  our  patient  manifest  symptoms  of  serious  organic 
disease,  or  give  a history  of  having  suffered  previously,  over 
a protracted  period,  after  a constitutional  anaesthetic  had  been 
administered,  or  should  our  patient  be  a pregnant  female,  or  a 
very  young  child,  and  the  operation  be  one  not  attended  with 
the  division  of  large  blood  vessels  and  occupying  but  a short 
time,  then,  local  anaesthesia,  if  any,  should  be  preferred.  With 
nervous,  apprehensive  patients,  though  we  but  merely  make  a 
“show,”  and  impress  them  that  we  are  employing  our  best 
efforts,  to  diminish  their  sufferings,  the  effect  will  be  most 


—24— 


INDICATIONS  FOR  LOCAL  ANAESTHETICS. 


salutary;  and  though  vve  accomplish  nothing  in  the  way  of 
direct,  local  annihilation  of  sensation;  yet,  when  we  are 
through,  our  patient  will  often  declare  that  we  gave  him  no 
pain. 


Mechanical  Anesthesia. 

There  are  very  many  instances  of  surgical  intervention, 
which,  by  the  skilled  and  judicious  application  of  force  and 
the  employment  of  instrumentation,  pain  may  be  greatly  di- 
minished, or  wholly  obviated. 

In  adjusting  certain  fractures,  or  reducing  dislocations, 
the  careless  inadept,  will  inflict  a vast  amount  of  pain  and 
torture;  but,  the  obdurate  spasmodic  contraction  of  the  mus- 
cles refuses  to  yield,  or  will,  only  in  a measure  relax,  and  the 
operator  fails.  In  the  gentle  and  skilled  hand  of  the  master,  but 
little  or  no  resistance  is  offered  by  that  muscular  fibre,  which 
may  be  coaxed,  as  it  were,  but  not  forced.  The  latter  begins, 
by  drawing  out  his  patient;  feeling  them;  psychologically,  so 
to  speak;  he  gains  their  confidence  and  inspires  them  with 
hope;  now,  he  turns  to  the  limb,  and  by  a process  of  sham- 
pooing, massage,  extension,  pressure,  etc.,  “puts  the  muscles 
asleep;”  when,  with  a sudden  dexterous  movement,  effects 
immediate  approximation  of  the  fragments,  or  returns  the 
head  of  the  luxated  bone  into  its  socket. 

An  ample  and  varied  supply  of  properly  constructed  in- 
struments, kept  in  proper  condition,  when  judiciously  em- 
ployed are  of  infinite  value  in  abbreviating,  simplifying  and 
rendering  surgical  operations  less  painful  and  dangerous.  A 
clean  cut,  with  a keen  edge,  is  much  more  painless  than  when 


26  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 


an  incision  is  made  with  a dull  scalpel,  which  requires  two  or 
three  strokes,  to  divide  the  integument.  Sharp-pointed 
needles,  of  a proper  size,  make  the  closing  of  a wound  a rapid 
and  painless  procedure.  Therefore,  it  may  be  said,  that 
mechanical  anaesthesia,  constitutes  in  itself,  an  aid  of  vital 
importance  in  all  operations;  but,  particularly,  in  those  wherein 
volatile  fluids  are  not  inhaled.  This,  of  course,  embraces 
every  detail  of  preparation;  as,  ample  assistance,  good  light 
and  perfected  dressings. 


Thermal  Anaesthesia. 

The  temperature  of  fluids  has  been  taken  advantage  of,  as 
an  anaethetic,  since  the  remotest  antiquity.  A low  temperature 
succeeds  the  best,  on  the  surface,  while  increased  heat  is  the 
most  serviceable  on  the  nude  tissues.  Cold  is  a powerful  car- 
diac depressant.  It  drives  the  blood  from  the  surface  to  the 
internal  organs;  and,  when  locally  applied  continuously,  first, 
it  chills  the  surface.  In  this  state  of  chilling,  the  parts  will 
endure  the  quick  incision  of  an  abscess,  the  removal  of  a 
splinter,  etc.,  without  pain. 

If  cold  is  long  continued,  a sensation  of  pain  sets  in,  to  be 
promptly  followed  by  numbness.  This  is  the  second  stage  of 
freezing.  Now,  many  surface  operations,  which  do  not  ex- 
tend into  the  deep  parts  may  be  conducted,  withont  severe 
suffering  or,  indeed,  any  great  distress. 

Third  Stage  of  Frigorific  Consolidation. — This  en- 
tails the  total  annihilation  of  sensation  and  complete  suspen- 
sion of  vitality.  The  part  en  bloc,  is  temporarily  dead.  This 


INDICATIONS  FOR  LOCAL  A NsE  S THE  TICS. 


■27 


state  is  imperative  in  finger  amputations,  bone  grattage,  or  re- 
section, in  onychia,  surface  necrosis,  etc. 

If  great  care  be  observed,  no  serious  harm  to  the  tissues 
may  follow,  after  this  freezing  process;  but,  in  many  cases,  it  is 
quite  impossible  to  avoid  accident,  and  a gangrenous  sore 
may  follow,  much  more  troublesome  than  the  condition  for 
which  the  surgical  operation  was  undertaken.  At  the  present 
day,  with  other  safer  agents  at  our  command,  it  cannot  be 
said  that  this  severe  degree  of  freezing  is  justifiable.  In 
my  hands,  in  many  operations,  in  which  the  effects  of  a local 
benumbing  of  the  parts  has  disappeared  before  the  operation 
is  completed,  the  free  irrigation  of  the  nude  surfaces,  with 
water  of  one  hundred  and  forty  degrees  (140°),  exerts  a 
marked  sedative  action.  It  gives  tone  to  the  heart,  favors 
hasmostatis,  and  blunts  the  sensability  of  the  nerve  fibrils. 

Ether  evaporation  is  the  most  effective  and  convenient 
means  for  local  anaesthesia.  With  it,  we  can  gauge  with 
precision  the  extent  and  depth  of  tissue-anaesthesia.  In 
the  absence  of  this,  then,  we  may  accomplish  something, 
with  broken  ice  placed  in  a rubber  cloth  or  bag.  But,  it  is 
better  to  apply  the  ice  directly  to  the  skin,  for  a moment,  and 
then  cut.  The  ice-water  douche,  the  water  being  poured  from 
the  neck  of  a pitcher,  raised  some  feet  above  the  patient,  has 
often  proved  serviceable  in  my  pratice. 

Mode  of  Application. — In  all  cases,  in  which  it  has 
been  decided  to  employ  local-anaesthesia,  there  are  certain 
conditious  and  details  necessary  to  observe,  in  order  to  attain 
the  greatest  measure  of  success.  These  refer  to  the  general 
condition  and  local  state  of  the  parts.  It  is  well,  when  oppor- 


28  LOGAL  ANAESTHETICS  AND  COCAINE  ANALGsESlA. 

tunity  permits,  to  operate  two  or  three  hours  after  a full  meal. 
The  patient  should  be  moderately  dosed  with  alcoholic  stimu- 
lants. Anything  from  champagne  to  brandy  maybe  employed. 
This  should  be  commenced  an  hour  before  operation.  The 
patient  should  be  placed  on  the  back. 

If  we  are  to  operate  on  a limb,  the  part  for  division  should 
be  thoroughly  prepared  and  isolated  by  sterilized  towels. 
When  anaesthesia  has  been  effected.,  we  must  have  everything 
in  readiness,  and  go  through  the  operation  with  all  possible 
celerity. 

It  may  be  said,  of  local-anaesthesia,  that  there  are  com- 
paratively few  cases  in  which,  through  it,  sensation  is  wholly 
suppressed.  The  patient  is  almost  invariably  conscious  of 
more  or  less  pain.  This,  however,  constitutes  no  valid  objec- 
tion against  its  employment  in  general;  but,  on  the  contrary,  in 
certain  types  of  pathological  conditions  it  is  an  advantage. 
These  cases,  in  which  but  partial  anaesthesia  is  desireable  may 
be  grouped  in  two  classes: 

First,  The  arthroses. 

Secondly,  The  feeble,  and  those  suffering  from  organic 
disease. 

There  is  a numerous  class  of  joint-neuroses,  in  which  in- 
flammatory changes  may  be  present,  in  a moderate  degree,  or 
wholly  absent,  that  may  derive  great  benefit  from  sudden 
psycological  and  physical  impressions.  It  is  through  fear,  that 
in  our  time,  practitioners  do  not  sufficiently  often,  avail  them- 
selves of  these  agents,  as  therapeutical  aids. 

In  that  class  of  cases  designated,  in  surgical  nomencla- 
ture, as  pseudo-anchyloses;  those  stiff,  painful  joints,  following 
an  injury,  particularly,  in  impressionable,  hysterical  individuals, 


INDICATIONS  FOR  LOCAL  ANAESTHETICS. 


29 


the  moderate  infliction  of  pain,  in  association  with  skilled  and 
cautious  manipulation  often  produces  remarkable  results. 

With  this  class,  the  charlatan  and  the  bone-setter  work 
wonders. 

One  has  wrenched  the  shonlder,  elbow,  wrist,  hip,  knee  or 
ankle.  The  patient  is  assured  by  the  medical  attendant,  that 
perhaps,  the  injury  is  but  trivial.  The  patient  is  particularly 
urgent  to  know,  if  there  be  a fracture  or  dislocation.  The 
limb  is  perhaps  immobilized,  or  possibly  the  case  is  dismissed 
with  a liniment,  or  the  patient  is  directed  to  apply  cold  ap- 
plication. But,  joint  distraint  remains,  with  more  or  less  pain, 
and  all  the  parts  over  the  seat  of  injury  are  exquisitely  sensa- 
tive  to  pressure. 

In  vain  our  patient  applies  from  one  physician  to  another; 
in  the  meantime,  consulting  with  the  most  eminent;  but,  possi- 
bly, all  agree  that  no  bone  is  broken  and  no  joint  displaced. 
Yet,  the  limb  remains  practially  crippled,  the  leg  will  refuse 
to  support  the  body  or  the  grip  power  in  the  hand  is  nearly 
lost.  It  naturally,  is  quite  incomprehensible  to  the  invalid, 
how  it  is,  that  if  there  is  no  serious  damage  inflicted  on  the 
limb,  it  still  remains  of  little  or  no  use  to  him.  At  last,  with 
patience  exhausted,  and  in  a state  of  despair,  his  friends  spirit 
him  away  to  the  hydropathist  or  the  “natural  bone-setter,”  who 
has  come  to  town,  for  a brief  stay.  The  former,  has  made  a 
deep  study  of  hydro-therapy  and  is  thoroughly  familiar  with 
the  marvelous  properties  of  douches  at  varying  temperatures; 
combined  with  massage,  passive  motion,  bandage-pressure,  and 
physological  rest.  He  immediately  secures  his  patients  con- 
fidence, by  his  gentle  and  painless  manipulation  of  the  limb. 
The  joint  gradually  limbers  out;  natural  warmth  returns,  the 


30  LOCAL  ANAlS  THE  TICS  AND  COCAINE  ANALGESIA. 

nutrition  of  the  structures  improves  and  in  a while  perfection, 
or  approximate  perfection  of  function  is  restored. 

The  natural  bone-setter  accomplishes  the  same  purpose;  but 
by  a shorter  route.  Immediately,  on  seeing  the  limb,  he  will 
declare  that  “the  bone  is  out”  and  assures  his  patient,  that  nec- 
essarily the  first  step,  demanded,  is  reduction  of  the  displace- 
ment. 

Our  patient  is  thoroughly  unnerved;  for,  he  instinc- 
tively appreciates  what  suffering  this  entails.  Now,  the  opera- 
tor with  great  alacrity,  before  the  apprehensive,  awe-stricken 
patient  has  recovered  himself,  seizes  the  affected  member,  and 
with  a quick,  but  cautions  motion,  gives  the  joint  a twist,  flexes 
and  fully  extends  it.  As  the  adhesions  give,  loud,  audible 
snaps  are  heard;  the  patient  groans  or  screams;  when,  almost 
at  once,  after  seizing  the  limb,  it  is  liberated.  The  patient  is 
now  commanded  to  walk,  if  it  be  the  lower-extremety  which 
was  manipulated;  and,  much  to  his  amazement,  he  can  do  so, 
without  pain  or  difficulty. 

I have  long  since  discarded  pulmonary-anaesthetics  in 
liberating  this  class  of  anchyloses.  In  those  cases,  in  which 
the  anchylosis  was  liberated  under  ether,  though  the  limb  was 
freely  movable,  yet  the  patient  was  timid  and  wanting  in  con- 
fidence, so  that  he  would  not  exercise  it  himself;  without 
which,  of  course,  in  forty-eight  hours  the  joint  was  as  stiff  as 
ever. 

Hence,  in  all  those  cases  after  fracture  or  other  traum- 
atism, in  which  it  is  important  to  overcome  the  anchylosis 
promptly,  the  results  are  more  satisfactory  and  permanent 
when,  but  partial;  topical  anaesthesia  is  affected,  by  douching: 


INDICATIONS  FOR  LOCAL  ANAESTHETICS. 


31 


and,  now,  all  adhesions  are  completely  sundered;  while  our 
patient  is  in  full  possession  of  his  senses. 

Illustrative  Cases. 

Case  i. — Patient,  a Spanish  lady  of  immense  avoirdupois, 
weighing  nearly  300  pounds.  This  lady  had  been  injured  in 
her  right  shoulder,  six  months  previously,  by  a fall  down  the 
stairs  of  one  of  our  elevated  railroad-stations.  After  she 
slipped,  she  fell  with  great  force  and  struck  on  the  right  arm 
and  shoulder.  She  suffered  considerably  from  shock  by  the 
fall  and  had  to  be  carried  home  in  a carriage.  After  a few 
days  rest  in  bed  she  recovered  fairly  well,  except  for  the  con- 
dition of  her  shoulder  and  arm.  After  the  family-physician 
had  tried  the  usual  remedies  for  sprains  and  contusions,  and 
the  limb  not  improving,  a distinguished  surgeon  saw  the  case. 
Now  immobilization  was  tried,  but  no  improvement  followed. 
Then  she  was  etherized  and  forcible  motion  employed,  with 
the  same  result.  She  then  went  to  a neurologist  who  in- 
formed her  that  the  brachial-plexus  was  probably  lacerated 
and  that  she  had  neuritis.  Medicines  were  given  and  electric- 
ity locally  applied,  repeatedly;  all  with  no  benefit.  For  a 
month  before  I saw  her,  she  had  given  up  every  description  of 
treatment. 

When  she  came  under  my  care  her  general  condition 
was  very  fair.  She  denied  ever  having  had  rheumatism  or 
neuralgia.  No  evidence  of  organic  disease.  The  arm,  from 
the  shoulder  down,  was  quite  helpless.  The  shoulder  could 
be  drawn  backward  and  forward,  inward  and  rotated  slightly; 
but,  the  power  to  raise  the  arm  was  lost,  and  all  range  of  mo- 


32  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 


ion  was  greatly  limited.  The  grip  of  the  hand  was  feeble  and 
the  strength  of  the  forearm  was  greatly  diminished.  There 
was  no  impairment  of  sensation.  On  the  contrary,  at  the 
shoulder,  it  was  markedly  exalted,  even  on  moderate  pressure. 
The  head  of  the  humerous  moved  freely  within  the  glenoid- 
cavity. 

After  a careful  examination  of  the  case,  it  was  clearly 
apparent  to  me,  that  the  limitation  of  motion  was  entirely  at- 
tributable to  an  organized  residue  of  inflammation;  which  oc- 
cupied the  thecal  lumina  of  the  tendons,  the  muscle-sheaths 
and  the  intra-muscular  spaces.  I was  hopeful,  that  the  or- 
ganic changes  had  not  yet  involved  the  parenchymatous 
elements  of  the  muscles,  and  that  the  vascular  apparatus  was 
unimpaired. 


Liberation  of  the  Joint. 

The  patient  was  given  three  ounces  of  brandy,  then  she 
was  placed  sitting,  on  a low  stool,  and  the  entire  arm,  from 
the  hand  to  the  thorax,  was  steamed  with  towels,  wrung  out  in 
water  as  hot  as  could  be  borne.  The  shoulder  was  deeply 
imbedded  in  these  for  about  ten  minutes,  when  the  parts 
were  annointed  with  sweet  oil.  Now,  motion  was  commenced 
in  various  directions;  the  head  of  the  bone  was  steadied  with 
one  hand,  while  with  the  other  leverage  action  of  the  arm 
was  effected.  No  great  difficult}'  was  encountered,  until  the 
upward  motion  was  essayed.  Now,  she  gave  a loud  scream, 
and  fell  over  into  the  nurse’s  arms  in  a swoon.  At  the  same 
instant  I was  able  to  liberate  all  the  firm,  unyielding  adhesions 
which  held  down  the  humerous.  I was  satisfied,  that  the  fib- 


INDICATIONS  FOR  LOCAL  ANAESTHETICS. 


38 


rous  anchylosis  had  been  overcome.  She  soon  rallied. 

After  a few  moments  rest,  she  commenced  to  move  her 
arm  in  various  directions,  greatly  to  the  surprise  of  her  husband 
and  children.  I saw  her  but  twice  after.  She  promptly  re- 
covered full  and  permanent  control  of  the  limb;  and,  as  motion 
and  strength  returned,  all  pains  and  lameness  vanished.  This 
was  a typical  case  in  which  to  test  the  merits  of  avulsion, 
without  general  anaesthesia.  It  was  insisted  in  this,  as  well  as 
in  all  similar  cases,  that  exercise  and  gymnastics  be  kept  up, 
until  function  was  fully  restored. 


Elbow-Joint  Anchylosis. 

True  and  false  anchylosis  are  very  common  after  violent 
wrenches  and  fractures.  The  pseudo-anchyloses  are  the  most 
common  in  young  children,  who  take  pulmonary  anaesthetics, 
rather  badly.  Their  stiffened  joints  need  passive  motion,  often 
repeated;  so  that  the  frequently  repeated  inhalation  of  a volatile 
lethal  agent  must  be  productive  of  injury  to  the  organs.  I 
have  found  in  these  cases  that  alternate  hot  and  cold  douching 
of  the  surface  seems  to  exert  a happy  influence  in  stimulating 
the  circulation  and  annulling  in  part,  sensation,  thereby  dis- 
pensing with  ether  or  chloroform. 

Case  2. — This  case  illustrates  a pseudo-anchylosis  at  the 
elbow-joint  with  treatment  by  partial,  surface,  thermal  anjes- 
thesia.  Patient,  36  years  of  age,  and  a major  in  the  militia. 
While  in  camp  with  his  regiment  he  was  thrown  from  his 
horse,  striking  the  ground,  on  his  elbow.  The  joint  was  badly 
sprained.  He  was  excused  from  duty  and  returned  home  with 


34  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGsESIA. 

a stiff,  swollen  joint,  and  the  most  intense  pain  down  along 
the  course  of  the  branches  of  the  median  nerve  in  the  fore- 
arm. No  fracture  nor  luxation  could  be  detected.  The  various 
remedies  had  been  tried  on  him,  without  much  benefit,  the 
elbow  remaining  painful  and  stiff. 

One  month  after  the  injury,  Dr.  R.  J.  Fitzgerald,  under 
whose  care  he  finally  came,  turned  the  case  over  to  me,  as  he 
said,  he  believed  radical  measures  were  called  for  to  overcome 
the  stiffness  at  the  joint,  which,  was  becoming  more  and  more 
aggravated,  with  time. 

His  general  conditions  when  he  came  to  me,  was  good,  but, 
he  was  quite  despondent,  at  the  prospects  of  having  a crippled 
arm  for  lite.  All  the  parts  about  the  elbow  were  tumified  and 
sensative,  and  the  fore-arm  was  quite  immovably  fixed,  at  a right 
angle  with  the  arm.  He  had  pain  through  the  flexor  surface  of 
the  arm,  and  he  couid  only  close  his  fingers  with  difficulty.  In 
this  case,  I found,  that  the  alternate  cold  and  hot  pack,  greatly 
alleviated  the  pain  and  permitted  of  more  or  less  action  in  the 
joint.  Indeed,  I was  able  to  quite  overcome  all  resistance  by 
the  thermal  anaesthesia  as  an  aid  to  subdue  pain.  He  made 
no  outcry,  and  confessed  that  it  surprised  him  that  the  anchy- 
losis could  be  so  readily  overcome.  He  was  directed  to  keep 
up  active  massage  and  gymnastics.  He  returned  to  his  posi- 
tion, as  an  architect,  the  next  week,  and  since  has  had  good 
use  of  his  limb. 

Case  3. — Patient,  a boy,  8 years  old,  who,  two  months 
bofore,  had  fallen  from  a fence,  a distance  of  eight  or  ten  feet, 
to  the  pavement,  striking  on  his  right  hip.  After  lying  in  bed 
four  or  five  days  he  was  allowed  to  get  up,  but  could  only 
move  about  by  using  a chair  or  a crutch.  He  was  seen  soon 


INDICATIONS  FOR  LOCAL  ANAESTHETICS. 


35 


after  this,  by  a practitioner,  who  pronounced  his  condition  hip- 
disease,  and  at  once  placed  the  joint  in  a g)  psum  dressing, 
which  extended  from  the  trunk  to  the  toes,  on  the  effected 
side.  The  parents  becoming  impatient,  as  they  were  warned 
that  hip-disease  pursued  a very  chronic  course,  I was  invited 
in  to  see  the  case.  A careful  examination  convinced  me,  that 
there  was  no  articular  disease,  but  the  immobilized,  rigid  joint 
was  fixed,  by  a pseudo-anchylosis. 

Therefore,  at  my  first  visit,  after  steaming  the  hip  with 
repeated  hot  packs,  and  by  using  but  moderate  force,  I was 
able  to  readily  overcome  the  muscular  adhesions  which  pre- 
vented the  free,  gliding  motion,  so  necessary  in  the  unimpeded 
action  of  the  muscles.  Recovery  of  full  use  of  the  limb  was 
rapid  and  complete,  and  in  two  weeks  from  that  time  he 
walked  without  a limp  to  my  residence,  a distance  of  over  a 
mile. 

As  the  knee-joint  is  devoid  of  a muscular  envelope  anteri- 
orly, we  less  frequently  encounter  a false  anchylosis  there,  than 
in  other  articulations,  though  it  is  occasionally  seen,  general 
ly,  of  a type,  which  does  not  require  the  application  of  force 
to  over  come  it. 

Although  the  same  anatomical  peculiarity  subsists  at  the 
ankle-joint  as  the  knee,  yet,  after  certain  traumatisms,  persist- 
ent stiffness  obtains,  with  limitation  or  suppression  of  motion, 
and  painful  locomotion;  which,  will  require  force  to  overcome 
it.  This  is  well  illustrated,  in 

Case  4. — Patient,  14  years  old,  wrenched  her  ankle  by  a 
fall  nearly  a year  previously.  For  a considerable  space  of 
time  she  was  unable  to  put  any  weight  at  all,  on  the  foot. 


36  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAZSIA. 

After  several  weeks,  by  the  aid  of  a crutch,  she  was  able  to 
move  about,  by  keeping  the  knee  flexed  and  the  foot  off  the 
ground.  She  wore  various  orthopaedic  apparatuses,  but  the 
state  of  pes  equinus,  or  raised  heel,  remained.  Her  parents,  in 
despair,  sent  her  the  rounds  of  our  numerous  dispensaries  and 
hospitals,  but,  without  any  substantial  improvement.  She  re- 
mained a cripple. 

It  is  needless  to  say,  that  through  forced  inaction  of  the 
limb,  in  the  growing  child,  there  were  both  mnscular  atrophy, 
and  shortening.  But,  on  a most  painstaking  examination, 
there  was  no  decisive  evidence  of  organic  changes  in  the 
osseous  or  arthritic  elements  of  the  joint  effected.  It  was  my 
impression,  that  the  joint  was  wholly  free  of  disease,  and  that 
it  was  immobilized  entirely  by  the  several  muscles  which  were 
adherent  by  a former  myitis;  and  contracted  through  non-use, 
over  so  long  a time.  Our  patient  was  prepared  for  the  break- 
ing down  of  the  adhesions,  by  having  the  foot,  ankle  and  leg 
freely  shampooed  and  douched  with  water,  as  hot  as  could  be 
borne,  for  half  an  hour;  when  the  foot  was  seized,  and  the 
ankle  fixed.  Now,  by  firm,  steady  motion  for  a moment,  the 
adhesions  were  heard  and  felt  to  give  way;  the  muscles  elong- 
ated, and  full  motion  was  restored  at  the  ankle-joint.  In  this 
instance,  although  there  was  considerable  pain  experienced 
when  the  adhesions  gave  way,  yet,  on  manipulation  of  the 
foot,  that  exquisite  sensativeness  of  the  integument,  so  marked 
on  entrance,  had  been  quite  overcome. 


CHAPTER  IV. 


MODUS-OPERANDI  OF  THE  THERMAL  AGENTS 
IN  REDUCING  THE  PAIN-SENSE. 


Sudden  and  intense  cold  act  by  the  extraction  of  heat, 
the  contraction  of  the  capillaries,  and  the  coagulation  of  the 
albumen;  when,  continued  long. 

When,  only  the  ephemeral  effects  of  cold  are  required,  as, 
in  making  an  incision  through  the  integuments,  then  our  pur- 
pose is  accomplished  by  producing  a local  chill  or  shock  to 
the  sensory-nerve  filaments.  Cold  congeals,  hardens  and  in- 
creases the  rigidity  of  muscular  fibre.  Frigorifics,  when  car- 
ried to  a certain  degree,  so  completely  coagulate  the  blood, 
and  empties  the  capillaries,  as  to  constitute  a useful  styptic. 
Wherefore,  why  cold  fluids  serve  a useful  purpose,  especially 
in  open,  lacerated  wounds;  when  the  parts  often,  are 
benumbed  by  the  trauma;  when  any  crushing  pressure  has  been 
borne;  and,  often  certain  areas  of  sensation  are  inhibited  by  the 
division  of  nerve  branches.  The  germicidal  potency  of  a low 
temperature  has  been  disputed;  but,  in  healthy,  aseptic  wounds, 
Nature  will,  unaided,  complete  repair  without  the  cold  fluid 
infecting  the  tissues;  and,  though  it  will  not,  like  intense 
heat,  destroy  all  microbic  atoms,  it  will  suffice  in  many  cases, 
where  necessity  requires  it,  as  a benumbing  agent. 


—37— 


38  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGTESIA. 

There  are  certain,  interesting,  clinical  peculiarities  about 
thermo-therapeutics.  In  one  class  of  cases,  fluids  of  a low 
temperature  will  immediately  relieve  pain  and  produce  a most 
refreshing  impression,  while  in  others  of  the  same  type,  hot 
cataplasms  are  most  grateful,  and  cold  intensifies  pain.  As  a 
general  rule  cold,  icy  applications  are  great  pain-appeasers, 
over  the  head;  though  heat  is  prompt  and  energetic  on  any 
part  of  the  trunk.  Intense  cold  acts  as  a depressant,  for  a 
period,  devitalizing  the  parts. 

Heat  is  rather  an  analgaesic  than  an  anaesthetic  when 
locally  employed  within  limits.  Its  action  is  totally  unlike 
cold.  It  stimulates  the  circulation,  produces  a relaxation  of 
all  contractile  tissues,  particularly  the  walls  of  the  capillaries. 
Its  local,  derivative  action  is  utilized  for  infinite  purposes 
by  the  medical-practitioner.  It  produces  a stimulant  action 
in  all  the  tissues,  and  sharpens  nerve-sense  when  first  applied; 
but,  as  its  application  is  continued,  and  perhaps  increased, 
sensation  is  diminished.  Its  action  is  modified  by  different 
pathological  conditions.  In  the  presence  of  inflammation  it 
reduces  pain  and  accelerates  tissue  metamorphosis. 

Heat,  like  cold,  is  a powerful  haemostatic;  though  its 
action  is  dependent  on  totally  dissimilar  phenomena.  Moder- 
ately cold  liquids  close  the  bleeding  points  by  vital  processes, 
and  heat  by  chemical.  But,  heat  exercises  no  anodyne  action 
on  open  lacerated  tissues  to  such  an  extent  as  to  reduce  their 
sensibility  to  pain  on  manipulation;  besides,  to  produce  its 
styptic  action,  the  temperature  of  liquids  must  be  raised  to 
nearly  the  boiling-point;  when  they  indiscriminately  coagulate 
all  the  albuminous  elements;  and,  over  nude  bone  surfaces. 


THERMAL  AGENTS  IN  REDUCING  PAIN. 


39 


lead,  by  their  irritating  action,  to  an  ultimate,  low  grade  of 
osteo-myelitis. 

Heat,  then,  in  surgery,  as  an  analgesic  of  moderate  utility, 
may  be  advantageously  employed,  over  the  unbroken  surfaces, 
and  chiefly,  in  the  class  of  arthroses  and  muscular  anchyloses 
cited. 


Brevity  of  Surface  or  Local  Anaesthesia. 

Safe,  peripheral  anaesthesia  is  transient.  This  implies 
the  need  of  dexterity  and  rapidity  of  execution,  in  operating. 
In  our  times,  of  all  things,  attention  to  detail  and  minutia  in 
the  preliminaries  of  an  operation  are  imperative.  This  applies 
to  every  species  of  surgical  intervention.  But,  in  the  absence 
of  a pulmonary  anaesthetic  it  is  of  pre-eminent  importance. 

The  old  operators  cultivated  the  art  of  celerity  in  manipu- 
lation, to  a very  high  degree.  Civiale,  we  are  informed,  sel- 
dom occupied  more  than  fifty  seconds  in  cutting  for  and  ex- 
tracting a calculus  frcm  the  bladder  ( Le  Medicitie  Moderne, 
June  7,  1889).  Any,  average  operator  could  disarticulate  at 
the  hip-joint  in  from  forty  to  eighty  seconds.  Now,  the  pre- 
vailing impression  is,  that  haste  is  essential  to  success,  only,  in 
abdominal  operations.  But,  this  certainly  is  incorrect,  for, 
everything  else  considered,  the  shorter  the  operative  time,  the 
more  certain  is  operative  success;  and,  ultimate  recovery, 
without  serious  sequelae.  Therefore,  with  everything  in  readi- 
ness, good  light,  and  ample  assistants,  the  most  painful 
part  of  many  operations  on  the  human  body,  may  be  per- 
formed within  thirty  minutes.  Certainly,  operations  on  the 
bones,  and  within  the  cavities,  will  consume  much  more  time. 


40  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

But,  in  any  event,  as  the  integument  and  cellular  tissue  only, 
are  highly  sensitive  to  pain,  after  a cavity  has  been  opened, 
we  penetrate  a region,  practically  devoid  of  painful  sensation. 
Very  many  times,  have  the  healthy  viscera  of  the  cranium, 
spinal  cord,  thorax,  and  peritoneal  cavity,  been  pricked,  and 
gently  compressed  by  me,  in  operations,  while  consciousness 
was  in  tact,  without  the  least  pain  being  elicited. 

Therefore,  if  we  effectually  obtund  sensation,  for,  but  a 
moment  or  two,  an  enormous  gain  is  made,  both  for  our  pa- 
tients’ safety  and  our  own  convenience.  This  can  be  accom- 
plished in  a large  number  of  cases.  We  are  often  placed  in 
embarrassing  situation,  by  our  patient,  when  a promise  is  ex- 
acted from  us,  that  we  will  give  them  no  pain.  They  may 
prove  refractory  to  local  anaesthesia,  or  possibly,  we  may  en- 
counter unexpected  difficulties  in  operating.  If  we  have  an 
opportunity  to  moderately  inebriate  our  patient,  this  difficulty 
can  be  partly  obviated.  It  would  be  interesting  to  learn,  if 
there  is  any  diminution  of  the  reparative  energy  of  the  tissues 
and  their  resisting  power  against  the  introduction  of  sepsis,  by 
the  use  of  those  chemical  agents  which  saturate  the  whole 
system,  before  the  full  coma  of  ether  anaesthesia  is  produced. 

An  aseptic  wound  favors  primary  union.  This  ideal  we 
have  obtained,  so  that,  in  this  direction,  we  need  look  for  no 
improvement.  Very  probably,  if  gain  there  be  to  the  patient, 
by  limiting  the  employment  of  chemical  anaesthics,  it  must 
apply,  rather  to  the  general  system,  than  to  the  local  condi- 
tion of  the  wound. 


CHAPTER  V. 


DETAILS  OF  TECHNIQUE  IN  THERMAL- ANAES- 
THESIA AND  APPROPRIATE  CASES. 

Thermal  anaesthesia  may  be  produced; 

First,  by  evaporation. 

Second,  by  fluids  in  motion. 

Thirdly,  by  co7igealed  zvater  and  salt. 

Sulphuric  ether  is  the  agent  most  commonly  selected  for 
local  purposes.  It  is  pulverized  by  a spraying-apparatus. 
The  parts  having  been  previously  prepared,  we  commence  by 
limiting  the  area,  on  which  we  propose  to  operate. 

Ether  atomization  is  seldom  employed,  except  on  unbro- 
ken surfaces,  and  must  be  confined  to  a narrow  field,  so  that 
we  will  fail,  or,  do  harm,  if  we  try  to  cover  too  much  space, 
at  one  time.  Spraying  should  be  commenced  slowly;  and,  as 
numbness  sets  in,  and  the  skin  begins  to  blanche,  it  should  be 
pressed  quickly,  for  a moment;  in  the  meantime,  being  cau- 
tious, that  the  parts  are  not  too  deeply  congealed,  when  our 
incision  is  quickly  made.  Our  operation  completed,  cold 
water  should  be  applied  in  order  that  the  local  reaction,  is  not 
too  rapid. 


—41— 


42  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

It  is  obvious,  that  the  field  for  local  anaesthesia,  by  the 
ether  spray,  is  a limited  one.  Hence,  it  is  safe  and  efficacious 
only  in  those  cases,  in  which  a simple  incision  is  to  be  made, 
or  in  some  very  short,  trivial  operation  on  parts,  which  lie 
near  the  surface;  as  in  abscess,  superficially  located;  for  the 
removal  of  splinters;  diminutive  cutaneous  papillomata,  etc. 

Agitated  Water. 

The  anaesthetic  power  of  cold  water  is  greatly  exhanced  by 
applying  it  in  rapid  motion,  and  suddenly.  For  this  purpose,  a 
syphon  of  ice-chilled  carbonated  water,  quickly  squirted  over 
the  operative  field  is  of  marvelous  efficacy  in  dulling  the  pain 
sense  in  the  integument  to  the  keen  edge  of  the  scalpel;  and, 
giving  us,  an  anaemic  incision.  In  the  absence  of  the  gaseous 
liquids,  a pitcher  of  ice-water,  poured  from  two  or  three  feet 
in  height  on  the  surface,  in  my  hands,  has  often  served  me  an 
admirable  purpose.  Either  of  those  simple  expedients  is 
equally  as  useful  as  ether-spraying;  in  a large  number.  It  is 
devoid  of  its  dangers,  and  always  accessible. 

A mixture  of  crushed  ice  and  common  salt  is  a potent, 
freezing  compound,  but  its  application  is  attended  with  so 
much  pain,  and  its  action  is  to  destructive,  that  its  employment 
can  seldom  be  justified.  It  had  been  utilized  before  the  dis- 
covery of  ether  in  amputation  cases;  but,  gangrene  so  com- 
monly followed,  that  it  was  very  generally  condemned. 

Larry,  however,  it  appears,  in  military  surgery,  had 
employed  it  with  varying  success  in  the  Russan  campaign,  in 
a few  amputation  cases;  but,  he  emphasized  its  dangers  and 
unreliable  effects  (“ Des  amputations  dans  les  membres  in- 


TECHNIQUE  IN  THERMAL- ANAESTHESIA. 


43 


ferior  es,  memoires  de  M.  le  Baron  Larry"  tome  6,  p.  417). 
I have  never  had  any  experience  with  this  species  of  frigo- 
rific.  An  extended  consideration  of  its  use  would  be  of  no 
practical  value;  for,  only  from  an  historical  standpoint,  has  it 
any  interest  at  all. 


IF^IR/r  TWO. 


CHAPTER  VI. 
COCAINE  ANALGzESIA. 


Of  all  the  greatest  discoveries  in  this  century  there  is  prob- 
ably none  in  the  whole  domain  of  medical  science  which  exceeds 
in  importance,  that  one,  through  which  the  profession  was 
given  that  inestimable  boon,  Cocaine  Analgsesia.  For  one  to 
behold,  the  painless  penetration  of  an  eyeball,  the  division 
of  tissues,  excision  of  tumors,  benign  and  malignant,  the 
canalization  of  the  trachea,  trephining  of  the  skull,  and  an  al- 
most infinite  number  of  other  surgical  operations,  seems  more 
like  a dream  or  a vision,  than  a realistic  fact. 

The  discovery  of  pulmonary-'anaesthetics,  about  fifty 
years  ago,  wrought  a prodigious  revolution  in  the  principles  of 
surgery.  There  was  no  species  of  surgical  operation,  that  it 
did  not  make  its  impress  on.  The  whole  professional  world 
seized  on  them,  almost  at  once;  and,  in  a little  while,  their 
employment  was  the  general  rule  in  every  manipulation  at- 
tended with  pain.  By  them,  the  operative  time  was  greatly 
protracted,  so  that  the  operator  was  permitted  greater  leisure, 
and  those  grave  pathological  conditions,  formerly  discarded  as 


COCAINE  ANALGESIA. 


45 


unsuitable  for  the  surgeon’s  knife,  were  now  brought  within 
the  range  of  legitimate  surgery. 

The  success,  nay!  the  very  possibility  of  abdominal  and  pel- 
vic surgical  operations  was  quite  out  of  the  question  until  the 
time  came,  that  the  sensory  functions  of  the  nervous  system 
could  be  temporarily  inhibited.  These,  are  time  consuming  op- 
erations. In  pre-antiseptic  times  they  all  had  been  essayed;  but 
given  up;  because,  of  the  impossibility  of  carrying  out  an 
efficient  technique,  within  a serous  cavity,  while  a patient  was 
writhing  and  groaning  under  severe  pain.  Many  other  regions 
of  the  body,  are  now  opened  to  the  surgeon,  through  the 
agency  of  anaesthetics. 

Now,  if  we  could  be  assured,  that  while  consciousness  and 
pain  are  suspended  during  the  progress  of  operation;  that  our 
patient  were  the  more  effectually  secured  against  shock; 
that  the  administration  of  ether,  or  chloroform  in  itself,  is  not 
attended  with  danger  and  unforseen  accidents;  and,  that,  in 
many,  suffering  from  organic  disease,  its  administration  is 
not  attended  with  risk,  then,  there  would  be  scarcely  any  ad- 
vantage to  be  gained  by  the  substitution  of  another  agent. 

But,  we  do  know,  that  while  the  mental  faculties  are  in 
abeyance,  and  all  conscious  sensation  to  mutilation  is  lost, 
still  animal  instinct  remains,  and  the  economy  yet  pre- 
serves its  impressibility,  when  vital  structures  are  exposed  or 
mutilated.  Thus,  we  will  observe,  that  commonly,  when  a 
serous  cavity  is  freely  opened,  the  pulse  becomes  nearly  im- 
perceptible, a deathly  palor  covers  the  features,  and  the  res- 
piratory functions  are  seriously  disturbed.  In  many  pro- 
tracted operations,  the  most  profound  collapse  may  succeed. 
There  is  a state  of  such  extreme  depression  occasionally  wit- 


46  LOCAL  ANAESTHETICS  AND  COCAINE  ANAL  GALS  I A. 

nessed,  that  it  is  out  of  all  proportion,  with  the  extent  of 
operation;  which  condition  by  different  surgeons,  notably,  the 
late  B.  A.  Watson,  was  designated  “Ether-Shock.” 

It  would  be  a work  .of  supererogation  to  speak  of  the 
deadly  potency  of  chloroform.  Its  lethality  is  enormous;  and, 
if  we  could  only  secure  reports  of  all  the  mortal  cases  and 
group  them,  their  number  would  be  appalling.  This  agent 
kills  with  such  alarming  suddeness,  in  many  cases,  that  pro- 
phylaxis is  out  of  the  question.  Nor,  does  it  appear,  that  safe- 
ty lies  in  a combination  or  dilution  with  other  anaesthetic  fluids. 

As  many  constitutional  infirmities  preclude  the  em- 
ployment of  general  anaesthesia,  we  cast  atfout  us  for  some- 
thing, which  may  be  employed,  as  a substitute,  when  we  wish 
to  annul  pain.  Erythoxylene,  or  the  alkoloid  of  coca,  in  a 
large  measure,  possesses  all  the  advantages,  with  but  few  of 
the  objections  of  pulmonary  anaesthetics,  in  a large  number  of 
operations. 


Cocaine. 

The  alkaloid  of  erythroxylon-cocaine,  is  the  most  power- 
ful local  analgaesic  known.  It  is  rather  a remarkable  coin- 
cidence, but  nevertheless  true,  that  the  medical  profession  is 
indebted  to  America  for  the  first  efficient  pulmonary  anaes- 
thetic; and  that,  the  coca-tree,  which  yields  the  leaves  from 
which  cocaine  is  extracted,  grows,  and  thrives,  only  in  South 
America  — in  Peru,  and  the  adjacent  states. 

In  1855,  Gardake  discovered  in  coca  an  alkaloid,  to  which 
he  gave  the  name,  erythoxylene;  a name,  by  which  it  is  at 
present  known  in  the  United  States,  and  British  Pharmaco- 


COCAINE  ANALGAESIA. 


47 


pceias.  This  principle,  however,  had  been  studied  earlier  by 
Dr.  Albert  Meinan,  who  gave  it  the  name,  cocaine. 

We  are  informed,  that  from  the  days  of  the  Incas,  coca 
had  been  employed  by  the  natives  of  Western  South  America 
in  enormous  quantities  as  a stimulant,  and  a tonic  against 
hunger  and  fatigue.  About  forty-millions  pounds  are  said  to 
be  harvested  annually  in  Peru. 

It  was  not  until  1884  that  Carl  Roller  first  discovered  the 
potency  of  cocaine  as  a local  analgaesic;  when  he  employed  it 
in  the  surgery  of  the  eye.  To  Paul  Reclus  are  we  indebted 
for  its  introduction  into  general-surgery,  for  describing  the 
technique  of  its  application  subcutaneously,  and  for  classifying 
the  cases,  in  which  it  may  be  most  appropriately  employed. 

Cocaine  is  heavier  than  morphine,  its  atomic  elements 
being,  Cn  H,  NO*.  It  is  a crystaline  alkaloid.  Applied  over 
the  tongne,  it  not  only  annuls  sensation,  but  destroys  taste. 
Physiologically,  it  is  a cardiac  and  respiratory  stimulant.  The 
pulse  is  rendered  firmer  by  its  administration,  and  its  beat  is 
more  rapid.  Breathing  is  also  rendered  more  rapid  and  shal- 
low, In  moderate  doses,  its  action  is  mostly  exhilerating,  and 
stimulating.  In  lethal  doses,  it  effects  all  the  senses.  Vision 
is  blurred,  there  is  ringing  in  the  ears,  the  pulse  is  quick  and 
irregular;  and  it  is  but  slightly  narcotic. 

In  England,  a physiological  committee  concluded,  that 
in  cocaine-paralysis,  the  terminations  of  the  sensory  nerves, 
and  the  posterior  columns  of  the  cord  were  effected;  while  the 
anterior  columns  escsped.  (“Ringer’s  Therapeutics,”  9th  Ed., 
p.  610). 

The  alkaloid  is  largely  eliminated  by  the  kidneys  (when 


48  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

given  in  large  doses);  though  ordinarily,  it  disappears  by  oxi- 
dation. 

The  hydrochlorate  is  the  form  generally  used.  This  is 
freely  soluble  in  water,  and  readily  assimilated. 

A phenate  of  cocaine  has  been  recently  put  on  the 
market,  which,  it  was  supposed,  might  be  preferred  for  dermic 
or  hypodermic  employment;  but,  as  it  is  insoluble  in  water, 
and  can  be  liquified  only  with  alcohol,  it  is  extremely  irritat- 
ing, and  causes  much  pain,  when  injected. 

Solutions  of  cocaine  act  with  great  energy  on  the  mu- 
cous-membranes when  locally  applied.  When  thus  utilized, 
its  action  varies  in  different  situations.  The  integument  is 
proof  against  it  in  normal  conditions;  but  when  the  seat  of  itch, 
or  the  pain  of  inflammation,  the  drug,  in  strong  solution, 
affords  great  relief  here. 

Difference  in  the  Degree  of  Susceptibility  and 
Diversity  of  Action. 

It  is  said  that  children  are,  proportionally,  more  suscep- 
tible to  its  action  than  adults;  and,  that  women  are  not  only 
less  resistant,  but  that  its  manifestations  with  them  are  often 
peculiar  and  erratic.  As  infants  and  young  children  are  not 
good  subjects  for  surgical-cocainization,  it  must  be  very  rarely 
employed  with  them,  unless  under  special  circumstances. 
There  can  be  no  question,  but  that  the  sensorium  is  pro- 
foundly effected  in  the  greater  number  of  females,  when  co- 
caine is  subcutaneously  employed,  in  anything  like  large 
dosage.  With  them,  it  seems  to  have  a special  affinity  for 
the  cerebral  centres,  and  to  act  less  satisfactorily  as  a sensory 
paralysant  when  injected. 


COCAINE  ANALGAiSIA. 


49 


Haemostatic  Properties  of  Cocaine. 

Cocaine,  locally  employed  in  surgical  operations  is  a 
haemostatic  of  the  first  order.  It  possesses  this  property  by 
its  action  as  a vaso-motor  paralyser,  the  smaller  arteries  and 
capillaries  being  effected  in  the  highest  degree. 

When  applied  in  a strong  solution,  over  the  mucous- 
membrane  of  the  more  vascular  areas  in  the  body,  it  so  effect- 
ually induces  anaemia,  that,  on  incision,  scarcely  any  blood  is 
lost.  This  is  very  beautifully  demonstrated  in  the  operations 
over  the  nasal-septum,  or  any  district  of  the  Schneiderian- 
membrane,  when  it  is  applied,  by  a swabbing  of  the  surface. 
In  consequence  of  the  styptic  property  of  the  drug  which, 
however,  continues  but  a few  moments,  we  must  be  on  the 
alert,  when  we  employ  it,  for  secondary  haemorrhage,  or  a 
troublesome  oozing,  after  the  dressings  are  applied.  But  this 
seldom  or  never  occurs,  except  in  operations  in  the  nasal 
cavities. 


CHAPTER  VII. 


TECHNIQUE  OF  ADMINISTRATION,  WHEN  TOP- 
ICALLY OR  SUBCUTANEOSLY  EMPLOYED, 

AS  AN  ANALGESIC,  IN  SURGICAL 
OPERATIONS. 


As  the  action  of  cocaine,  as  an  analgsesic,  is  very  trans- 
ient, not  lasting  more  than  twenty  to  thirty  minutes,  it  is  im- 
portant that  every  preparation  is  complete,  when  we  depend 
on  this  agent.  It  must  be  administered  rapidly;  and,  after 
some  definite  method. 

In  plastic  or  other  operations  on  any  mucous-membrane, 
except  the  conjunctiva,  or  in  the  nasal-cavities,  hypodermica- 
tion  must  be  conjoined  with  surface-applications. 

Topical  Application. 

Cocaine  solutions  applied  over  a mucous  surface  should 
be  of  greater  strength  than  when  injected  into  the  tissues. 
From  a four  to  a ten  per  cent  solution  is  required  for  this 
purpose;  but,  of  this  strength  it  should  be  used  very  sparingly. 
Perhaps,  the  only  exception,  when  a solution  of  diminished 
density  is  required,  is  in  the  case  of  a sensative,  irritable,  or 
inflammed  urethra.  Many  accidents  have  been  reported 


—50— 


TECHNIQUE  OF  ADMINISTRATION. 


51 


when  strong  solutions  have  been  injected  into  this  tubular 
structure. 

When  solutions,  of  any  strength,  have  been  injected  into 
a passage,  we  should  always  tje  assured,  that  after  a moments 
stasis,  they  are  completely  drained  away.  The  lodging  of 
pieces  of  sponge,  gauze,  or  cotton,  over  an  open  wound,  or 
mucous  surface,  is  not  a safe  practice,  when  saturated  with  a 
strong  solution  of  cocaine.  As  a rule,  the  safest  and  most 
efficient  plan  is  to  swab  over  the  surface  to  be  manipulated, 
with  a well  soaked  pledget,  and  see  to  it  that  the  residue  is 
displaced  before  operative-measures  are  commenced.  It 
may  be  sometimes  necessary,  in  the  course  of  an  operation,  to 
reapply  the  analgaesic,  when  much  time  is  occupied,  or  sensa- 
tion is  not  amply  obtunded. 


Hypodermic  Use  of  Cocaine. 

To  accomplish  the  most  satisfactory  results,  requires  con- 
ditions, which  have  reference,  to: 

First,  the  Individual. 

Seconly,  the  Local  Parts. 

Thirdly,  the  Medicament  Itself. 

Fourthly,  Its  Mode  of  Administration. 

The  Individual. 

As  the  susceptibility  to  cocaine,  varies,  and  the  cumu- 
lative action  of  the  drug,  is  never  to  be  lost  sight  of,  its  admin- 
istration is  always  rendered  safer  and  the  more  effective,  by  the 
moderate  ingestion  of  alcoholics;  a little  while,  before  the 


52  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAESLA. 

operation,  when  there  are  no  contra-indications.  Our  patient 
should  have  had  ample,  bodily  rest,  and  when  an  extreme, 
nervous  apprehension  is  present,  a moderate  dose  of  opium, 
taken  the  night  before  the  operation,  steadies  and  sustains 
the  nervous  system.  The  patient  may  have  a moderate  meal, 
an  hour  or  so  before  our  operative  intervention  commences, 
when  the  digestive  organs  are  in  good  condition. 

When  we  are  permitted  the  selection  of  time,  the  morn- 
ing hours  are  to  be  preferred,  in  this,  as  in  all  other  classes  of 
operations.  My  custom,  with  respect  to  the  administration  of 
alboholics,  is  to  have  it  commenced  about  one  or  two  hours 
before  cocainization  is  begun.  The  sparkling,  strong  wines, 
or  distilled  liquors  may  be  used,  according  to  our  patients 
choice,  or  the  special  circumstances  of  the  case.  Slight, 
moderate  inebriation  is  an  adjuvant  of  very  great  value,  in 
cocaine  operations.  It  not  only  aids,  in  inhibiting  the  sen- 
sorium,  but  it  likewise  serves,  in  enabling  the  system  to  resist 
the  effects  of  shock,  or  loss  of  blood. 

Cocaine,  in  lethal  dosage,  inhibitits  cardiac  and  respira- 
tory action,  through  the  cerebral  centers.  This  action  is 
antagonized  or  minimized,  by  fortyfying  the  system  with 
alcoholic  stimulation,  which  antidotes  this  toxic  property  of 
the  drug,  by  its  well-known  effects,  on  the  cephalic  ganglia. 
When,  however,  our  patient  has  an  aversion  to  taking  stimu- 
lants, it  should  be  respected,  and  they  should  not  be  forced 
on  them;  unless,  such  symptons  arise,  during  the  progress  of 
the  operation,  as  imperatively  demand  their  use. 

Individual  Idiosyncrasies. 

It  should  always  be  rembered,  that  certain  individuals 


TECHNIQUE  OF  AD  MINIS  TRA  7 ION. 


53 


manifest  a remarkable  and  dangerous  susceptibility  to  various 
drugs.  I have  witnessed  a case,  in  which,  two-thirds  of 
a grain  of  the  extract  of  opium,  brought  on  a mortal 
coma.  I have  known  the  same  calamity  follow,  one-fourth 
grain  of  morphine;  injection,  hypodermically.  Such  acci- 
dents we  cannot  foresee,  but,  in  the  case  of  cocaine,  hypoder- 
mically employed,  we  may  forestall  them,  in  most  instances. 

Many,  especially  females,  will  go  into  syncope,  after  the 
prick  of  a hypodermic-needle,  or  on  seeing  a little  blood.  It 
would  be  unfair,  in  these  cases,  to  attach  all  the  blame,  for 
such  mishaps,  to  cocaine;  for,  in  many,  not  a drop  of  the  solu- 
tion, has  entered  the  tissues,  when  our  patient  swoons  away,  in 
a dead  faint. 

In  a considerable  number,  of  so-called,  cocaine  accidents, 
I am  inclined  to  believe,  from  the  published  descriptions  of 
many  of  them,  that  they  have  been  nothing  more,  than  this 
phase  of  mental  shock. 

We  will,  in  all  instances,  examine  critically  into  the  con- 
dition of  the  internal  organs — the  kidneys,  heart  and  lungs 
particularly;  and  adopt  such  precautions,  as  will  obviate  serious 
symptoms. 


The  Medicament. 

It  is  very  probable  that  many  of  the  mishaps  and  grave 
accidents  which  have  occurred  in  hypodermication  of  cocaine, 
were  attributable  to  an  inferior  septic  solution,  or  a faulty 
technique. 

When  we  are  about  to  employ  the  alkaloid  hypodermically, 
the  solution  should  be  made  fresh,  if  possible.  The  water, 


54  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

and  the  vial  to  contain  the  solution  should  be  sterilized.  It 
should  be  heated  to  about  ioo°  F.;  about  the  temperature  of 
the  blood,  before  injection.  As  a general  custom,  it  is  better 
to  make  our  solution  fresh  from  tablets,  as  needed,  than  to 
employ  stale  fluids. 

Cocainized  water  promptly  decomposes,  unless  hermetic- 
ally closed  in;  therefore,  when  rendered  septic,  and  injected 
directly  into  the  tissues,  contamination  is  almost  certain  to 
follow.  Decomposed,  stale  solutions  lose  their  potency,  in  a 
large  measure,  as  analgaesics.  This  will  often  explain  why 
hypodermic  injections  are  often  inert.  The  usual  strength  of 
solutions,  for  hypodermic  employment,  is  too  great  and  dan- 
gerous; and,  is  not  any  more  efficient  than  those  much  weaker. 
For  ordinary  purposes,  a one-per  cent  solution  will  suffice. 
One  drop  of  carbolic  acid,  to  the  dram,  will  preserve  the 
solution. 

The  general  rule  jor  the  volume-dosage  hypodermically 
employed,  in  the  adult,  is  not  to  exceed  that  by  the  mouth; 
or,  from  one-eighth  of  a grain  to  two  grains.  In  my  own 
practice,  I have  very  rarely  had  occasion,  to  use  more,  than  the 
equivalent  of  one  grain. 

The  syringe , used  in  the  hypodermication  of  cocaine 
should  have  a long,  strong  needle.  The  larger  the  barrel,  the 
better.  One  constructed  of  metal,  for  many  obvious  reasons, 
is  to  be  preferred.  This  is  all  the  more  desirable,  in  a syringe  of 
the  required  strength  for  cocainization,  because  much  more 
firmness  is  required  in  an  instrument  used  for  this  purpose, 
than  in  ordinary  hypodermication;  when,  nothing  more  is 
needed  than  to  send  the  liquid  into  the  loose  cellular  tissues. 
But,  in  cocainization,  we  must  often  inject  into  very  resisting 


TECHNIQUE  OF  ADMINISTRATION.  55 

tissues,  as  the  tendonous,  ligamentous  and  cartilaginous.  (Cod- 
man  & Shurtleff,  of  Boston,  Mass.,  manufacture  the  strongest 
hypodermic-needle  in  this  country). 

The  technique  of  cocaine-hypodermication  should  be  faith- 
fully carried  out,  in  all  cases,  if  we  would  the  more  effectually 
inhibit  sensation,  over  the  operative  area.  The  surface  having 
been  thoroughly  sterilized,  our  solution  at  hand,  the  syringe 
is  cleansed  and  tested;  it  is  then  charged,  when  we  proceed  to 
first  make  “a  hub  and  a circle  of  spokes.”  This  is  what  my 
good  friend,  Dr.  Joseph  Price,  of  Philadelphia,  designates 
Reclus’  radial,  injection  scheme.  The  needle  is  sent  into  the 
collar,  when  we  simultaneously  commence  two  movements. 
First,  to  slowly  press  down  the  piston,  and  secondly,  to  with- 
draw the  needle,  until  the  point  arrives  at  the  puncture,  but 
does  not  come  out  through  it;  when  the  needle  is  again  sent 
in,  at  another  angle,  and  in  a different  direction;  withdraw  in 
the  same  manner,  as  in  the  first  instance,  and  repeatedly  in- 
troduce, until  a considerable  circle  has  been  sprayed. 

With  this  plan,  by  three  or  four  punctures  or  “spokes” 
only,  in  the  integument,  a large  area  is  cocainized.  By  mak- 
ing but  few  punctures  through  the  skin,  pain  is  much  reduced. 
By  the  compound  movement  given  the  syringe,  while  inject- 
ing, and  withdrawing  at  the  same  movement,  we  avoid  de- 
positing a large  quantity  at  one  place;  and,  should  a vessel  be 
penetrated  by  the  needle’s  point,  but  a drop  or  two  is  sent 
into  its  lumen,  instead  of  the  whole  syringefull,  otherwise. 
Besides,  it  evenly  sprinkles  the  needle’s  path  in  such  a manner 
as  to  be  more  uniformly  diffused  through  the  tissues.  In 
trivial  operations,  but  one  “wheel”  is  made;  but,  should  we 
need  to  cover  a considerable  territory,  we  make  several. 


56  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAESIA. 

About  thirty  drops  are  needed  in  each  puncture;  from  three 
to  four  drops  in  each  radial  furrow. 

It  is  generally  imprudent,  to  send  the  needle  in  very 
deeply,  unless,  we  are  preparing  the  border  of  a large  tumor, 
or  are  about  to  deal  with  the  osseous  tissue.  The  skin  and 
cellular  membranes  are  the  most  abundantly  supplied  with  the 
filaments,  from  the  sensory  nerve  branches,  so  that,  our  aim 
should  be,  to  as  effectually,  deal  with  these  as  possible. 

When  we  are  about  to  operate  on  the  extremities,  then 
we  may,  when  our  operation  is  to  be  very  tedious,  employ 
Coming’s  method  of  confining  the  circulation,  and  extending 
the  period  of  the  anaesthetic  action  of  cocaine  by  passing  the 
elastic  bandage  around  the  limb,  above  the  operative  area. 
This  serves  the  double  purpose  of  preventing  the  drug  from 
entering  the  general  circulation,  besides,  limits  its  local  action. 
Our  injections  completed,  the  integument  is  kneaded  for  a 
moment;  when  the  surface  is  douched  with  an  ice-chilled 
syphon  of  carbonated  water,  where  the  primary  incisions  are 
to  be  made. 

In  all  operations  under  cocaine  hypodermication,  except, 
those  on  the  extremities,  in  which  the  diffusion  of  the  drug 
through  the  general  circulation  is  prevented  by  the  elastic 
constrictor,  we  should  make  our  incision  and  open  into  the 
tissues,  very  promptly,  after  our  field  is  prepared.  By  this 
course,  all  excess  of  the  alkaloid  is  washed  away  by  the  escap- 
ing blood,  and  the  chances  of  its  toxic  action,  reaching  the 
brain  centers  are  diminished.  As  the  analgaesic  action  is  com- 
paratively short  in  these  operations,  in  the  suturing  of 
an  extensive  incision,  unless  we  are  rapid  in  execution,  much 
suffering  will  be  borne  by  the  patient,  in  our  needle-punctures. 


TECHNIQUE  OF  ADMINISTRATION. 


57 


and  the  drawing  of  heavy  catgut,  or  silk  sutures  through  them. 

The  local  condition  of  the  parts,  in  all  cases,  requires 
special  notice.  Are  they  in  a normal  condition,  or  the  seat 
of  pathological  changes?  An  active  circulation,  at  the  seat  of 
operation,  is  a sine  qua  non  in  all  cases.  Therefore,  it  would 
be  futile  to  inflict  chemical  solutions  into  inanimate,  gangren- 
ous tissues.  In  cedematous  tissues,  more  of  the  medicament  is 
needed  than  in  the  healthy. 

Inflammation  is  no  contra-indication  to  the  hypodermic 
use  of  cocaine.  The  punctures  are  more  painful,  it  is  true, 
but,  as  there  is  an  increased  vascularization,  analgsesia  is  more 
prompt  here  than  in  the  normal  tissues.  It  goes  without  say- 
ing, that  a drug  of  the  potent  energy  of  cocaine,  must  be  em- 
ployed with  care  and  discrimination;  and,  that  its  careless  or 
injudicious  employment  may  be  attended  with  serious  dangers. 
One  of  the  most  cogent  objections  against  its  employment,  is, 
that  through  it,  a heterogenous  substance  is  admitted  into  the 
general  circulation  in  varying  quantities.  That  it  possesses 
lethal  properties  is  undisputed. 

The  toxic  action  of  cocaine  may  be,  as  a rule,  obviated  if 
we  exercise  ample  vigilance,  and  administer  the  drug  in  a 
diluted  dosage.  There  can  be  no  question,  but,  that  the 
strength  of  the  solution  for  hypodermic  dosage  as  set  forth  in 
the  current  treatises  on  Materia-Medica,  is  too  great.  My 
own  practice,  was  based  on  these  directions,  when  I first  used 
it;  but  it  was  unsatisfactory,  and  psychological  phenomena, 
with  toxic  symptoms,  were  common,  until  I reduced  the 
strength  of  the  solutions,  for  injection,  to  otie  per  cent. 

The  direction,  to  “wait  for  ten  or  fifteen  minutes,”  is 
wrong,  and  may  be  followed  by  evil  consequence.  This  delay 


58  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAES1A. 


permits  of  the  cocaine  being  taken  up,  by  the  circulation,  act- 
ing on  the  nerve-centers,  and  producing  constitutional  disturb- 
ances; while  the  very  essence  of  our  claim  for  it,  is,  that  its 
action  is  purely  local.  Accordingly,  we  must  so  adapt  tech- 
nique, that  its  action  may  be  confined.  With  this  object  in 
view,  in  a moment  after  its  injection,  the  surgeon  rapidly 
makes  his  preliminary-incision,  when  the  blood,  from  the 
peripheral  vessels,  washes  away  the  surplus  in  the  tissues. 
Nor,  am  I convinced  of  the  accuracy  of  those  recorded  fatal 
cases,  under  cocaine  injection;  though,  it  must  be  admitted, 
that  the  dosage  employed  was  dangerous. 

Biddle  (“Materia  Medica  and  Therapeutics,”  XII  Ed., 
p.  300)  says,  “fatal  results  have  followed  the  injection  of 
eighteen  drops  of  a twenty  per  cent,  solution  into  the  urethra;” 
and,  he  adds,  “that  the  smallest  mortal  dose  recorded  was 
eighteen  drops  of  a four  per  cent,  solution.”  The  passage  of 
an  instrument,  through  the  normal  urethra,  has  been  followed 
by  promptly,  mortal  consequences,  in  catheterizing  and  sound- 
ing for  a stone,  when  nothing,  whatever  has  been  injected. 
And,  mortal  shock  has  followed  here  too,  even  when  pulmon- 
ary anaesthetics  were  employed.  As  the  tendency  to  syncope 
and  dangerous  shock,  is  very  great  in  different  individuals,  the 
fear  of  this  haunts  every  conscientious  surgeon,  until  his  opera- 
tion is  performed. 

There  are  certain  parts  of  the  body  and  passages,  in  which, 
as  a rule,  cocaine  analgaesia  should  be  eschewed.  Any  part 
of  the  anterior  or  lateral  walls  of  the  thorax,  when  punctured, 
commonly  give  rise  to  great  and  inexplicable  shock.  I have 
seen  so  many  cases  of  the  most  dreadful  collapse,  after  stilleto- 
wounds  of  the  chest-wall  anteriorly,  that  I would  deem  it  a 


TE  CRN  IQ  UE  OF  A DM  IN  IS  TRA  TION. 


59 


dangerous  procedure  to  make  many  deep  needle  punctures 
here. 

The  mammary  gland  in  the  female  is  rather  more  tolerant 
than  other  areas  of  the  chest.  The  urethral  passage  is  another, 
noli  me  tangere,  for  cocaine,  as  a general  rule;  but,  when  proper 
precautions  are  employed  it  should  not  daunt  us.  In  my  own 
practice,  I have  never  had  any  mishaps  in  urethral  surgery 
and,  in  spite  of  what  has  been  written  against  it,  I must  up- 
hold this  priceless  agent,  for  many  purposes  in  the  surgery  of 
the  urethra. 

With  the  female  sex,  and  in  young  children,  the  hypodermic 
employment  of  cocaine, is  not  so  satisfactory  as  with  adult  males. 
Children  are  timid  and  frightened,  making  great  resistance  to 
the  punctures;  besides,  it  is  said,  like  opium,  in  childhoood,  to 
produce  cumulative  symptoms.  With  hysterical  women,  un- 
less we  operate  very  promptly,  the  drug  produces  marked  ex- 
citement, though,  in  the  average  case,  its  effects  are  most  grati- 
fying. The  common  gravamen,  of  the  female  sex,  is  the  pain 
of  the  injection,  the  needle  puncture,  etc.,  consequently,  the 
field  of  operation  should  be  concealed  from  their  views,  and 
the  needle  punctures,  rapidly  made.  It  has  been  charged, 
against  hypodermic  analgsesia,  that  in  many,  intense  pain 
is  borne  at  the  seat  of  incision,  after  its  effects  pass  off.  This 
may  have  been  the  experience  of  certain  operators,  but 
they  are  rare;  and,  but  few  such  cases  have  been  reported. 
We  may  notice  the  same  phenomenon  after  ether  or  choloro- 
form  in  highly  sensitive  individuals.  But,  a more  serious  ob- 
jection, if  it  could  be  substantiated,  has  been  advanced.  It 
has  been  thought,  that  in  consequence  of  the  vasomotor- 
paralysis,  which  it  induces,  that  it  impairs  the  nutrition  of  the 


60  LOCAL  ANAESTHETICS  AND  COCAINE  AN ALGAES1A. 

parts,  at  the  seat  of  operation,  and  greatly  retards  reparative 
processes;  that  primary  union  is  uncommon;  that  there  is  a 
proneness  to  suppuration;  and  in  operations  on  the  eye,  to 
ulceration  of  the  cornea,  and  a chronic  congestion  of  the  cho- 
roidal vessels. 

It  is  the  experience  of  every  one  accustomed  to  perform 
surgical  operations,  that  at  times,  for  some  unaccountable 
reason,  the  results  are  unsatisfactory;  wounds  may  take  on  a 
chronic  course;  a constitutional  irritability  may  follow,  and 
union  may  be  slow  and  imperfect.  Any  new  remedy,  or  in- 
novation in  surgical  therapy,  by  many  is  regarded  with  suspi- 
cion, and  we  are  sceptical  of  its  value  till  it  has  been  thoroughly 
tested.  This  has  been  the  history  of  the  most  valuable  agents 
we  possess.  Many  take  up  cocaine,  with  a deeply-rooted 
prejudice  against  it.  With  these,  every  shortcoming  or  mis- 
hap is  exagerated  or  magnified,  and,  if  miracles  are  not  real- 
ized, they  fiercely  condemn  the  new  agent.  With  one’s  first 
experience  with  a drug,  until  we  are  familiarized  with  it;  espe- 
cially one  requiring  the  precision  of  detail,  demanded  in  co- 
caine-hypodermication,  if  we  fail  at  our  first  trial  we  are  apt  to 
prematurely  cast  it  aside.  Certainly,  in  my  own  cases,  which 
embrace  a large  variety  of  operations  in  different  regions  of 
the  body,  on  various  tissues,  the  healing  processes  have  been, 
in  no  manner,  impaired  or  delayed. 


CHAPTER  VIII. 


SURGICAL  OPERATIONS  IN  WHICH  HYPODER- 
MIC COCAINIZ ATION  MAY  BE  EMPLOYED 
WITH  ADVANTAGE. 

Professor  Herman  Knapp,  in  his  brochure  entitled  “Co- 
caine and  Its  General  Uses  in  Ophthalmic  and  General  Sur- 
gery,” declared,  that  “no  modern  remedy  has  been  received  by 
the  profession  with  such  great  enthusiasm;  none  has  become 
so  popular,  and  scarcely  any  has  so  extensive  a field  of  useful 
application,  as  cocaine,  the  local  anaesthetic  recently  intro- 
duced by  Karl  Roller,  of  Vienna.”  This  author  avows,  that  his 
contribution  is  not  written  so  much  for  the  purpose  of  report- 
ing what  has  been  accomplished  in  various  hands,  as  to  stimu- 
late others  to  make  new  investigations.  This  eminent  surgeon 
experimented  on  his  own  person  by  making  injections  into  his 
own  urethra,  etc.  He  tell  us  that  he  removed  painlessly,  a 
deep  seated  aural  polypus  with  cocaine,  in  a perfectly  painless 
manner. 

The  following  are  some  of  the  experiments  and  views  of 
different  authors,  writers  and  operators,  collected  by  Dr.  Knapp: 
Dr.  W.  J.  Hepburn  ( Medical  Record,  Nov.  15,  1889),  “in- 
jected six  minims  ot  a two  per  cent  solution  under  the  skin 
of  the  arm.  In  forty-eight  minutes  he  made  eight  such  injec- 


-61- 


62  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAES1A. 

tions,  Immediately,  there  was  an  acceleration  of  pulse  and 
respiration;  an  agreeable  warmth,  moderate  mydriasis,  slightly 
crossed  diplopia,  agreeable  hallucinations,  with  the  eye  closed, 
disappearing  when  they  opened.  Impairment  of  cutaneous 
sensability,  and  a sense  of  walking  on  a cushion,  a tendency 
to  walk  on  the  heels;  a sensation  on  grasping  an  object,  that 
something  intervened  between  it  and  the  hand.  Two  other 
experiments  had  the  same  results.” 

This  experiment  of  Hepburn’s  was  a singularly  valuable 
one,  and  a few  features  of  it,  just  here,  are  worthy  of  special 
note.  It  will  be  observed,  that  he  made  the  injections  in  a 
very  leisurely  manner,  covering  four-fifths  of  an  hour;  that  he 
injected  nearly  a grain,  and  that  toxic  symptoms  were  well 
pronounced.  It  will  be  noted,  too,  that  all  that  was  injected 
remained  in  the  circulation. 

Should  such  sequellae  occur  in  general  surgery,  by  cocai- 
nization,  they  would  constitute  a very  grave  objection  to  it, 
but  as  has  been  observed,  when  we  employ  cocaine  hypoder- 
mically, as  a surgical  analgaesic,  we  must  be  ready  to  operate 
promptly,  after  the  drug  has  been  sent  into  the  parts,  and  that 
the  surplus  of  the  solution  is  washed  away  by  the  blood, 
escaping  from  the  divided  tissues.  It  produced  hallucinations, 
agreeable  sensations,  etc.  Some  have  gone  so  far,  as  to 
declare  that  it  may  cause  insanity.  But  there  is  no  proof,  in 
any  well-anthenticated  instances,  that  I can  find  of  such  a con- 
dition; that  could  be  clearly,  charged  to  the  drug,  when  em- 
ployed only  for  surgical  purposes;  though,  we  are  all  acquainted 
with  the  curse  of  the  cocaine  habit. 

Without  doubt,  mental  derangement  may  have  followed 
certain  operations  in  which  cocaine  has  been  employed,  but 


C 0 CA1N1ZA T10N  IN  SPECIAL  SURGiCAL  OPERATIONS.  63 


that  proves  nothing;  for  we  know  also,  that  there  are  op- 
erations on  certain  regions,  very  commonly  followed,  by  the 
most  marked  psychological  disturbances  when  ether,  chloro- 
form, or  even  no  anaesthetic  at  all,  is  employed. 

Dr.  Sears,  in  a recent  issue  of  the  Boston  Medical  Journal, 
considers  the  question  of  insanity,  following  surgical  opera- 
tions, and  has  collected  185  cases  of  all  kinds.  Sixty  followed 
gynaecological  operations;  ten  followed  amputation  of  the 
breast;  sixtytwo  resulted  from  operations  on  the  eye;  while 
forty-five  belonged  to  the  domain  of  general  surgery.  In  a 
list  of  cases  collected  by  Kiernan,  sixty-five  followed  gynae- 
cological operations,  and  thirty-five  cataract  operations.  I 
have  elsewhere  called  attention  to  peculiar  phase  of  persistent 
melancholia,  which  I have  observed,  after  operations  for  the 
radical  cure  of  reducible  hernia. 

Dr.  Knapp  tells  us  that  Drs.  A.  H.  Smith  and  S.  D. 
Powell,  of  New  York,  employed  cocaine  with  good  results  on 
the  urethra;  that  Von  Rambdor  operated  for  vaginisums  with 
it;  that  J.  W.  Mitchell  employed  it  with  advantage  in  venereal 
operations;  that  Cabot,  of  Boston,  used  it  in  urethral  surgery. 

Dr.  F.  N.  Otis,  of  New  York,  says,  that  he  used  it  with 
great  advantage,  in  cases  of  stricture,  enlargement  of  the  pros- 
tate, irritability  of  the  urethra,  stone  in  the  bladder  and  ulcer 
of  the  rectum. 

Dr.  VV.  H.  Doughty  operated  successfully  with  cocaine 
for  vesico-vaginal  fistula. 

Bosworth,  of  New  York,  has  employed  it  in  rhinological, 
and  other  operations  in  the  pharynx  and  larynx. 

Dr.  E.  L.  Keys  has  extensively  employed  it,  in  urethral 
surgery.  He  says,  that  it  seems  to  spend  its  energy  on  the 


64  LOCAL  ANAESTHETICS  AND  COCAINE  ANAL  GALS  I A. 


anterior  urethra  rather  than  the  deep,  and  on  the  peri-urethral 
tissues. 

Polk  has  employed  it  in  vasico-vaginal  fistulas.  The 
alkaloid,  it  appears,  is  highly  appreciated  as  a valauble  ad- 
juvant in  surgery,  on  the  Pacific  Coast. 

Dr.  S.  O.  L.  Potter,  of  San  Francisco,  Cal.,  says  (“Phar- 
macy and  Therapeutics,”  IV  Ed.,  p.  217):  “Cocaine  has 

achieved  a notoriety  as  a local  anaesthetic,  and  promises  to  be 
of  the  greatest  value,  in  many  operations  on  the  eye,  ear,  nose, 
throat,  uterus  and  urethra.” 

Lauder  Brunton,  speaking  of  erythroxolene,  in  his  valua- 
ble work  on  “Pharmacology  and  Therapeutics,”  says:  “The 

expectations  of  the  practicability  of  cocaine,  founded  on  a 
knowledge  of  the  physiological  action  which  Rossbach  ex- 
pressed, has  been  completely  fulfilled,  and  it  bids  fair  to 
replace,  as  an  anaesthetic,  chloroform,  in  many  minor  opera- 
tions.” 

Potter  and  Brunton,  evidently  had  not  familiarized  them- 
selves with  the  contents  of  Reclus’  brochure,  at  this  time,  or 
they  would  have  learned  that  cocaine  is  equally  as  valuable 
in  as  many  major,  as  in  minor  operations. 

A host  of  operators  the  world  over,  can  testify  to  the  in- 
finite value  of  cocaine  analgaesia;  but,  even  now,  a want  of 
knowledge  of  its  use;  timidity,  prejudice  and  sentiment,  have 
confined  its  employment,  within  too  narrow  limits. 

Alcohol,  ether  and  chloroform,  it  is  said,  are  antidotes  to 
cocaine,  when  toxic  symptoms  appear.  How  much  they  an- 
tagonize its  lethal  action,  I cannot  say,  from  experienca; 
but,  to  my  mind,  the  aromatic  diffusive  stimulants,  as  camphor, 
musk  and  ammonia,  would  serve  a much  better  purpose  in 


C0CAJN1ZA  TION  IN  SPECIAL  SURGICAL  OPERATIONS.  65 


arousing  the  patient,  and  overcoming  the  paralysis  of  the 
reflexes  when  an  antidote  is  called  for.  Cold-douching  of  the 
face,  hot  applications  over  the  precordia,  electricity,  plenty  of 
fresh  air,  friction,  the  “ procede  de  la  langue ” of  Le  Fort,  used 
in  asphyxia  or  sudden  apncea,  from  any  cause,  many  be 
utilized  with  advantage. 


The  Advantages  Which  Cocaine-Hypodermication  Offer 
in  the  Manual  of  Surgical  Operations. 

First,  As  to  the  price  of  the  drug  itself.  Cocaine,  to 
the  profession,  costs  but  a few  cents  a grain,  and  kept  dry, 
in  a tightly  covered  vial,  does  not  deteriorate  with  time.  The 
cost  is  a small  item;  yet,  it  is  worthy  of  notice. 

Second,  With  its  use,  we  may  dispense  with  assistants 
altogether,  in  many  operations;  and,  in  others,  reduce  their 
number.  This  is  an  important  matter,  as  in  many  cases,  as- 
sistants may  be  difficult  or  impossible  to  secure;  or  perchance 
our  patient  is  without  means  to  compensate  them.  Indeed, 
as  Reclus  puts  it,  our  patient  becomes  the  most  valuable  as- 
sistant himself;  moving  and  shifting  his  body  in  any  position 
we  may  direct. 

In  a village  or  scattered  neighborhood,  when  one  is 
called  in  the  night,  and  our  case  will  not  admit  of  delay,  to 
send  long  distances  for  assistants,  it  is  often  a priceless  boon. 

Third,  By  the  intelligent  employment  of  cocainization,  in 
oral  surgery,  or  the  surgery  of  the  nasal  or  buccal  cavities, 
the  operative  technique  is  greatly  simplified,  and  the  danger 
of  sucking  blood  into  the  air-passages  is  entirely  obviated. 

Fourth,  In-opportune  retching,  straining,  vomiting,  bron- 


66  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

chorrhoea,  expectorating,  hysterical  screaming,  and  groaning 
are  all  wanting. 

Fifth,  There  are  none  of  the  violent,  bodily  struggles 
and  resistance,  so  often  seen  in  the  excitement  stage  of 
ether  anaesthesia. 

Sixth,  Tetanic,  tonic,  or  clonic  spasms,  violent,  mus- 
cular contractions,  and  plunging  of  the  extremities  are  absent. 

Seventh,  The  patient  suffers  none  from  post-operative, 
gastric  disturbance,  so  general,  after  ether  or  chloroform. 


CHAPTER  IX. 


REGIONAL  AND  ANATOMICAL  DIVISIONS  OF 
OPERATIONS  FOR  COCAINIZATION. 

First. — Operations  on  the  Head. 

Second. — Operations  on  the  Neck. 

Third. — Operations  on  the  Trunk. 

Fourth. — Operations  on  the  Extremities. 

Fifth. — Operations  for  Traumatisms,  and  Pathological 
Conditions. 


Head. 

Chief,  among  the  conditions  of  the  head,  requiring  opera- 
tive intervention,  is  fracture  of  the  skull,  or  suspected  fracture 
for  which  incision  is  made,  to  expose,  and  elevate  the  bone, 
or  for  purposes  of  exploration.  The  skull  is  rarely,  if  ever 
fractured,  without  the  brain  participating  in  the  consequence 
of  the  trauma;  although  the  lesion  need  not  necessarily  manifest 
itself,  by  cerebral  symptoms. 

Now,  it  is  well  known  that  etherization  is  always  attended 
by  active  cerebral  congestion  and  hypersemia  of  all  the  Super- 
jacent tissues.  I have  often  watched  the  phenomenon  of  ex- 
pansion of  the  brain,  through  an  aperature  in  the  vault,  and  I 
have  seen  the  convolutions  rise,  flatten  out  and  fill  the  cranial 


—67— 


68  LOCAL  ANAESTHETICS  AND  COCAINE  A NAL  G AES  I A. 


cavity,  as  the  ether  inhalations  were  pressed  to  full  coma; 
then  noted,  as  anaesthesia  passed  off,  how  they  receded  away 
from  the  inner  table. 

In  fact,  cerebral  hyperaemia  is  an  essential  part  of  pul- 
monary anaesthesia.  But,  can  we  induce  this  state  when  the 
brain  is  damaged  by  injury,  with  impunity?  Does  it  not 
rather,  favor  the  prospects  of  meningeal  inflammation,  super- 
vening, or  retard  reparative  processes?  May  it  not  induce 
cerebral-hernia,  through  favoring  protrusion  of  brain-substance, 
in  the  direction  of  the  least  resistance,  when  the  dura-mater  is 
opened  by  accident,  or  the  surgeons  scalpel? 

At  all  events,  it  gives  us  a bloody  field  for  operations, 
and  the  vomiting  or  straining,  which  it  induces,  may  cause  a 
secondary  haemorrhage,  through  disturbances  of  the  wound. 

In  properly  seleeted  cases  of  gun-shot  injuries,  or  frac- 
tures of  the  skull,  cocainization  is  a most  useful  procedure. 
The  cases  of  this  class,  in  which  the  best  results  are  realized, 
are: 

First,  Those  in  which  the  patient  is  not  rendered  in- 
sensible, by  the  injury. 

Second,  Those  which  mainly  occupy  the  vault. 

Third,  Those,  in  which  we  are  assured,  that  the  operative 
manual  will  be  brief. 

Fourth,  In  adults,  when  delerium  is  absent. 


Technique  of  Cocainization,  in  Skull  Injuries. 

The  scalp  is  first  entirely  shaved  and  cleansed.  This 
should  always,  when  it  is  possible,  be  done  in  the  ward,  or 
before  the  patient  is  placed  on  the  operating  table.  In  skull 


REGIONAL  AND  ANATOMICAL  OPERATLVE  DIVISIONS.  69 


injuries,  we  deviate  from  the  usual  routine  in  our  preliminaries 
so  as  to  entirely  omit  the  administration  of  alcoholics.  The 
scalp  is  a tissue,  easily  cocainized;  besides,  as  we  wish  to 
prevent  cerebral  congestion,  we  deliberately  avoid  the  use  of 
stimulants.  The  patient,  now  in  position,  we  may  or  may  not 
encircle  the  head  with  in  Esmarch’s  bandage.  In  my  own 
practice,  it  is  seldom  employed  here.  Its  application  is 
painful.  In  young  subjects,  the  communication  between  the 
larger  meningeal  vessels,  through  the  diploe  to  the  scalp,  is 
so  complete  that  this  will  not  produce  complete  haemostasis. 

A circle,  from  four  to  five  inches  in  diameter,  may  be 
easily  cocainized  in  the  scalp  with  60  or  70  drops  of  the 
standard  hypodermic  solution.  Here,  it  will  be  noted,  that 
the  anatomical  conditions  favor  prompt  and  efficient  action  of 
the  hypodermic.  The  scalp  rests  on  the  bony  wall  of  the 
skull,  so  that,  not  like,  in  many  other  situations,  there  is  less 
chance,  of  the  liquid  penetrating  downward  into  the  deeper 
tissues.  The  scalp  is  very  vascular,  and  hence,  the  diffusion 
of  a medicament  through  it  is  very  rapid. 

Our  solution  injected,  we  douche  the  surface  with  a re- 
frigorant,  and  in  a moment  proceed  with  our  primary  in- 
cision. The  scalp  alone,  in  the  absence  of  inflammation,  is 
the  only  covering  of  the  dome  of  the  brain,  highly  endowed 
with  sensation.  We  effectually  benumb  sensation  in  the  tissue 
when  the  way  is  clear  for  the  painless  completion  of  our  op- 
eration. The  division  of  the  occipito-frontalis  tendon,  its  un- 
derlying fascia,  the  pericranium  and  plates  of  the  skull,  give 
no  pain,  as  we  penetrate  them. 

The  scalp  tissue  being  well  retracted,  and  the  pericranial 
membrane  being  well  drawn  aside,  we  are  on  the  depressed 


70  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAESIA. 


bone.  Now,  at  this  stage,  in  former  times,  we  would  take  up 
the  trephine  and  drill  out  a disc  of  bone.  But,  for  a long  time 
I have  cast  the  trephine  aside  altogether  in  this  class  of  cases, 
as  a dangerous  and  complicated  instrument,  liable  to  get  out 
of  order,  and  in  its  application  damaging  to  the  dura-mater. 
Instead,  we  now  employ  osteotomes  (square  and  bevelled  chis- 
els) and  the  mallet.  In  other  words,  we  substitute  what  the 
French  designate  debridement  for  trepanage.  In  the  hands  of 
one  of  ordinary  skill,  this  is  a safe,  simple  and  prompt  means 
of  elevating  the  fragments  of  crushed  bone.  The  depressed 
bone  removed  and  the  wound  cleared,  we  are  ready  to  replace 
the  soft  parts.  Usually,  before  this  is  completed,  the  anal- 
gaesic  effect  has  passed  away,  and  our  patient  complains  only 
of  the  needle  points  as  they  penetrate  the  scalp. 


Illustrative  Cases. 

As  examples  of  the  different  types  of  cranial  lesions,  it 
may  be  well  to  cite  a few  cases,  in  abstract. 

Case  One. — Compressed  and  Depressed  Fracture  of  the 
Skull,  of  Four  Years'  Standing. — Patient,  male,  48  years  old, 
was  injured  four  years  previously  by  being  struck  over  the 
vertex,  with  a falling  brick.  He  said  he  had  considerable 
bleeding,  at  the  time  of  injury,  and  went  to  a physician,  who 
bandaged  his  head,  and  ordered  a lotion.  The  wound  healed, 
but  two  years  later  it  re-opened.  He  now  went  to  a physician, 
who  sent  him  to  a hospital.  Here  he  was  told  that  there  was 
dead  bone  in  his  skull,  and  that  he  must  take  ether  in  order 
to  have  an  operation  performed.  But,  as  he  ha-d  a fear  of  ether, 


REGIONAL  AND  ANATOMICAL  OPERATIVE  DIVISIONS.  71 


lie  refused,  and  left  the  hospital.  Finally,  as  the  opening  in  his 
head  had  become  a great  source  of  irritation,  he  applied  to  the 
Harlem  Hospital  for  admission  and  treatment.  He  was 
assured  here  of  a painless  operation,  without  ether. 

The  head  was  shaven  and  prepared,  and  two  hours  after 
he  had  eaten  a moderate  dinner,  he  was  placed  on  the  operat- 
ing table.  About  two  inches,  anterior  to  the  occipital  protub- 
erance, directly  in  the  median  line,  squarely  over  the  longitudi- 
nal sinus,  there  was  a depression  of  the  bone,  indenting  the 
brain  in  such  a manner,  that  one  could  pass  the  middle  finger- 
down  from  the  level  of  the  skull,  nearly  an  inch.  At  the  bot- 
tom of  this  pit,  there  was  an  open  sinus,  through  which  a probe 
was  easily  passed,  on  to  nude,  necrosed  bone. 

This  was  thoroughly  cleansed  and  dried,  when  a small 
pledget  of  lint,  saturated  in  a four  per  cent,  solution  of  cocaine 
was  loosely  packed  in  the  cavity,  while  hypodermication  was 
being  carried  on  over  the  integument  above.  In  a few  mo- 
ments everything  was  ready,  the  skull  was  denuded,  an  open- 
ing made  near  a lateral  fissure  with  the  chisel,  when  an  eleva- 
tor was  introduced  and  a fragment  started.  Now,  with  the  aid 
of  a forceps  and  rougeur,  the  work  of  cleansing  away  the  dis- 
eased bone  was  rapidly  accomplished.  As  the  dura  mater 
was  exposed,  it  was,  in  different  places,  gently  pressed  with  a 
probe,  but  the  patient  was  scarcely  conscious  of  any  sensa- 
tion, and  had  no  sense  of  pain  from  the  pressure,  he  said; 
though  he  could  feel  the  scalpel  pass  through  the  tissues  and 
the  retractors  penetrate  the  scalp;  but,  there  was  no  suffering 
whatever.  He  made  a good  renovery. 


Case  Two. — Compound  Fracture  Through  the  Frontal 


72  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

Bone.— Patient,  male,  60  years  old,  was  struck  in  a brawl,  and 
knocked  down.  Was  dazed  by  the  blow,  and  unable  to  rise. 
Was  taken  to  the  station-house  on  a stretcher,  and  an  ambu- 
lance was  called;  when,  he  was  brought  to  the  hospital;  intoxi- 
cated and  boisterous,  when  admitted.  Wound  was  dressed,  he 
was  given  an  anodyne  and  placed  in  bed.  He  passed  a quiet 
night.  The  next  afternoon,  when  consciousness  was  restored 
fully  and  reaction  was  well  re-established,  he  was  placed  on 
the  table  for  examination,  and  treatment  of  the  fractured  skull. 
The  tissues  were  torn  widely  open,  and  shattered  bone  came 
into  view,  as  one  of  the  loose  flaps  was  pressed  aside. 

After  the  lacerated  tissues  had  been  carefully  sterilized, 
the  bleeding  was  subdued,  and  the  wound  dried.  Hypodermi- 
cation  was  commenced,  and  sixty  drops  injected.  While  this 
was  being  done,  a piece  of  cotton  gauze,  moistened  with  co- 
caine solution,  was  stuffed  into  the  wound.  Cocainization 
completed,  a syphon  of  ice-chilled  vichy  was  spurted  over  the 
traumatized  surface.  Now,  a long,  crucial  incision  was  made 
over  the  traumatized  area,  and  the  osseous  surface  of  the  skull 
exposed.  It  was  now  seen,  that  the  frontal  sinus  was  opened 
by  a fragment  of  bone  from  above  the  supra-orbital  ridge, 
which  was  driven  inward.  This  fragment  was  removed,  the 
edges  of  the  portal  now  made,  were  trimmed,  the  overlying 
integuments  replaced  and  sutured.  The  patient  at  no  time 
complained  of  any  pain.  His  ultimate  recovery  was  rapid. 

Case  Three. — Concussion  of  the  Brain,  With  Suspected 
Fracture  of  the  Skull. — Patient,  a carpenter,  fell  from  a staging, 
a distance  of  about  thirty  feet,  landing  on  a pile  of  bricks. 
He  was  raised  in  an  unconscious  state,  and  brought  into  the 


REGIONAL  AND  ANATOMICAL  OPERATIVE  DIVISIONS.  73 


hospital  in  an  ambulance.  I saw  him  the  day  following  ad- 
mission. He  now  had  possession  of  his  reason,  but  com- 
plained, at  this  time,  of  some  dizziness. 

A little  above,  and  anterior  to  the  tempero-parietal  junc- 
tion, there  was  an  apparent,  irregular  depression,  which  had 
some  of  the  characters  of  a depressed  fracture  of  the  skull. 
As  there  were  no  urgent  symptoms,  a temporizing  course  was 
adopted.  After  four  days,  as  the  parts  at  the  seat  of  the  in- 
jury still  presented  features  indicative  of  fracture,  we  decided 
to  cocainize  the  scalp  over  the  traumatized  area  and  explore 
for  fracture.  In  this  situation  it  will  be  noted  that  the  skull  is 
partly  covered  in  by  the  temporal  muscle,  and  is  more  deeply 
situated  from  the  surface  than  at  the  vertex. 

The  case  was  treated  essentially  on  the  same  lines  as  the 
previous  ones,  as  far  as  cocainization  was  concerned;  the  bone 
was  denuded  by  a very  tedious  detachment  of  many  fibres  of 
the  temporal  muscle;  but  no  fracture  could  be  detected.  The 
analgaesia  worked  perfectly.  Our  field  of  operation  was  quite 
anaemic,  the  head  motionless  and  no  resistance  offered.  The  sec- 
ond, though  one  attended  with  an  extensive  laceration  of  the  tis- 
sues, was  closed  without  drainage,  and  healed  by  primary  union. 

In  my  service  at  the  Harlem  Hospital,  within  the  past 
three  years,  more  than  twenty  fractured  skulls  have  been 
treated  by  cocaine  analgaesia,  in  operations  on  them.  It 
would  be  useless  to  occupy  space  in  rehearsing  them  here,  as 
it  is  enough  to  know,  that  in  the  majority  of  cases  of  cranial 
fracture  in  the  adult,  the  hypodermic  use  of  cocaine  wholly 
obviates  the  necessity  of  employing  any  sort  of  anaesthetic 
inhalation. 

If  it  has  any  special  lethal  properties,  when  employed  in 


74  LOCAL  ANAESTHETICS  AND  COCAINE  ANaLGaESIA. 

such  close  proximity  to  the  brain,  I am  unacquainted  with 
them.  It  is  easy  to  conceive  of  cases  of  this  description,  in 
which  sudden,  serious  symptoms  might  develop,  and  the  drug 
be  wrongly  condemned  for  them. 

On  July  16,  1893,  Dr.  James  H.  Bache,  of  this  city,  came 
for  me  in  a great  hurry  to  go  and  see  a patient  of  his,  a lad  of 
16  years,  who  had  accidently  shot  himself;  the  ball  penetrating 
just  above  the  left  supra-occipital  ridge.  At  my  house,  I sug- 
gested that  we  employ  cocaine  for  an  analgaesic,  but  the  doc- 
tor was  sceptical  of  its  powers.  The  wound  had  produced  no 
immediately  grave  symptoms,  and  the  boy  was  sitting  up,  with 
full  possession  of  all  his  faculties,  when  the  doctor  came  for 
me.  I told  him  that  it  would  take  about  an  hour  for  me  to 
prepare  and  reach  the  house.  When  I arrived  there,  the  lad 
had  suddenly,  been  seized  with  violent  convulsions,  so  that  the 
doctor  was  obliged  to  administer  chloroform  to  overcome  them. 

While  he  was  in  this  state,  I extracted  the  ball,  which 
was  lodged  between  the  dura-mater  and  the  inner  table.  Pass- 
ing my  finger  over  the  dura,  I noted  a total  absence  of  brain 
pulsation,  which  clearly  indicated  a sanguinous  effusion;  prob- 
ably from  some  of  the  lacerated  cerebral  vessels.  This  accu- 
mulation of  blood,  no  doubt,  by  intra-meningeal  pressure, 
caused  the  violent  spasms  and  loss  of  consciousness.  The  un- 
opened dura  crowded  into  the  bullet  opening  in  the  skull. 
The  boy  came  out  of  coma  towards  morning  and  has  since 
made  a good  recovery.  But,  had  I,  unluckily,  injected  a few 
drops  of  cocaine  solution,  before  the  boy  was  seized  with  this 
violent  convulsion  and  coma,  the  fiercest  maledictions  would 
have  been  hurled  at  me,  and  had  he  died  in  the  stupor,  the 
drug  might  have  been  held  accountable  for  the  boy’s  death. 


CHAPTER  X. 


PATHOLOGICAL  CONDITIONS  OF  THE  SKULL 
AND  BRAIN,  IN  WHICH  COC AINE-ANAL- 
GSESIA  IS  EFFICACIOUS  IN  SUR- 
GICAL OPERATIONS. 

There  are  many  lesions  of  the  skull  and  brain,  other  than 
those  of  a traumatic  origin,  which  are  ameable  to  surface 
anaesthesia,  when  surgical  intervention  is  demanded. 

Six  years  ago,  a young  man  came  into  my  service,  at  the 
Harlem  Hospital,  who  had  a scalp  wound  only,  as  was  sup- 
posed. This  was  dressed,  in  the  usual  manner,  when  he  was 
dismissed.  Two  weeks  later,  he  returned  with  an  ulcerated 
sore  at  the  former  seat  of  the  laceration,  and  under  this,  the 
bare  bone  could  be  felt  with  the  probe.  He  had  a severe 
headache,  great  tenderness  over  the  seat  of  the  wound,  bodily 
weakness,  chills,  thirst  and  fever.  It  was  now  decided  to 
cocainize  the  inflamed  indurated  tissues  at  the  seat  of  injury, 
and  explore;  for,  the  symptoms  all  pointed  to  deep  suppura- 
tion and  septicaemia.  The  scalp  was  prepared  in  the  usual 
manner,  and  cocainized.  As  the  scalp  flaps  were  rolled  away, 
we  came  on  a linear  fissure  on  the  skull,  through  which  fun- 
gous granulation  projected,  and  pus  oozed.  When  a one- 
inch  area  of  the  cranial  surface  was  exposed,  a small  trephine 


—75— 


76  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

was  taken  in  hand,  and  a button  of  bone  sawed  away.  This 
brought  us  down  on  a large  pus  formation,  lodged  between 
the  dura-mater  and  the  skull.  The  cavity  was  evacuated, 
flushed  and  drained,  and  dressing  applied;  analgaesia  of  cocaine 
serving,  most  happily,  to  annul  all  painful  sensations,  and  our 
patient  making  an  uninterrupted  recovery. 

On  July  16,  1893,  I operated  under  cocaine,  with  the  ut- 
most satisfaction,  in  a case  of  mastoid  abscess. 

Patient  was  a hearty,  vigorous  lady  of  30  years.  She  had 
been  suddenly  seized  with  violent  pain  in  her  right  ear.  This 
had  been  treated  by  two  practitioners,  with  the  usual  paliative 
measures  when  she  came  into  my  hands.  After  vainly  trying 
different  tentative  expedients,  and  finding  everything  pointing 
to  deep-seated  suppuration,  near  the  base  of  the  brain,  in  the 
mastoid  elements,  I urged  operation  under  cocaine.  At  this 
time,  her  general  condition  was  becoming  very  serious.  She 
had  incessant  neuralgic  pains,  pyaemic  symptoms,  loathing  of 
food,  no  natural  sleep,  profound  anaemia,  and  little  strength. 
Her  great  dread  of  operation  was  of  taking  the  ether;  this,  she 
had  a horror  of,  yet  she  demanded  an  assurance  that  we 
would  not  give  her  any  pain,  for  the  mastoid  district  was  as 
sensative  as  a ripe  phlegmon.  As  a preliminary  in  this  case, 
good  French  brandy  was  freely  given  for  an  hour,  before 
operation. 

With  one  assistant,  preparations  for  operation  were  begun; 
in  the  meanwhile,  a table  spoonful  of  brandy  was  given  every 
fifteen  minutes,  as  the  time  approached  for  division  of  the 
tissues.  Now,  with  the  side  of  the  head  shaved  and  sterilized, 
hypodermication  was  begun.  The  point  of  the  needle  was 
sent  deeply  into  the  indurated  tissues,  until  it  passed  under  the 


ANALGESIA  IN  CRANIAL  AND  BRAIN-OPERATIONS.  77 


pericranium,  when  the  spraying  of  the  inflammed  area  com- 
menced. Cocainization  and  refrigoration  completed,  the  tis- 
sures  were  painlessly  stripped  from  the  bone,  when  the  small 
trephine  was  engaged  in  the  osseus  elements  of  the  mastoid. 

The  bone  was  as  dense  and  as  compact  as  ivory;  hence, 
the  process  of  drilling  was  tedious  and  difficult.  But  at  length 
the  vitreous  plate  was  penetrated,  and  a mass  of  foul-smelling, 
greenish,  cheesy  pus  exposed.  The  trephine  opening  was  en- 
larged with  the  rougeur,  the  bony  pus-cavity  scraped,  and 
flushed  with  antiseptic  solution.  At  no  time  was  our  patient 
conscious  of  pain.  Her  recovery  was  tedious,  but  it  has  been 
complete. 

This  was  a typical  case  of  cranial  surgery,  in  which  to 
test  the  full  value  of  cocaine-analgaesia.  The  operative  area 
was  in  a state  of  acute  inflammation,  the  seat  of  disease  was 
deeply  lodged,  the  technique  was  complicated  and  tedious;  yet, 
never  has  the  drug  more  completely  fulfilled  its  purpose,  than 
in  this  lady’s  case. 


CHAPTER  XI. 


LOCAL  ANALGESIA  IN  HAL  MATO  MAT  A,  SMALL 
NEOPLASMS  OF  THE  SCALP,  IN 
SUSPECTED  CRANIAL-FRATURES 
AND  BRAIN  LESIONS. 


It  has  become  a well  recognized  practice,  in  modern 
times,  to  cut  down  on  and  clear  out  blood-clots  or  effusions  of 
blood  under  the  scalp,  rather  than  to  treat  such  cases  on  the 
old  lines,  when  lotions  were  applied,  bandage  pressure  was 
employed,  and  they  were  disposed  of,  by  the  more  tedious 
process  of  disentegration  and  resorption. 

For  many  reasons  the  modern  method  is  much  to  be  pre- 
ferred in  all  cases,  provided  the  haematoma  is  large  and  rigor- 
our  asepsis  be  employed. 

Everyone  who  has  had  anything  like  an  extensive  experi- 
ence in  scalp  or  skull  injuries,  is  familiar  with  the  peculiar  cup- 
shaped depression  which  we  so  often  find  in  those  simple 
haematomata  following  a blow,  in  full,  on  the  head.  The  hard, 
elevated  margin,  which,  takes  a different  outline  in  various 
cases,  so  simulates  a depressed  fracture  of  the  skull,  that  in  all 
such  cases  attended,  particularly,  with  cerebral  symptoms, 
the  inexperienced,  or  hasty  may,  on  finding  this  depression, 
assume  that  there  has  been  a fracture.  But,  the  fact  is,  in  the 


— 7£— 


C 0CA1N1ZA  TION  IN  SCALP  AND  SKULL  INJURIES.  79 

majority,  there  is  no  fracture;  and,  as  resorption  advances,  this 
deceptive  ridge  wholly  disappears. 

Nevertheless,  in  a certain  proportion,  when  the  base  of 
the  blood  tumor  presents  the  same  identical,  visible,  and 
tangible  qualities,  the  skull  has  suffered  a depressed  fracture. 
Hence,  by  opening  these  freely,  in  all  cases,  we  are  enabled  to 
explore  the  cranial  surface,  at  the  seat  of  the  injury  and  deter- 
mine whether  we  have  a simple  or  grave  lesion  to  deal  with. 

The  clot  is  displaced,  all  bleeding  subdued,  the  sterilized 
scalp-surfaces  are  closed,  without  drainage,  prompt  reunion 
follows;  and,  in  simple  cases,  we  secure  results  in  days,  which 
heretofore  accupied  weeks.  In  this  class,  the  hypodermica- 
tion  of  cocaine,  renders  operative  interference  a safe  and  simple 
procedure. 

It  is  quite  enough,  here,  to  simply  cocainize  only  the  line 
of  incision;  and,  twenty  or  thirty  drops  are  ample.  But,  in  all 
this  class  of  cases,  let  the  scalp  be  cleanly  shaven,  scrubbed 
and  sterilized.  It  is  well,  in  all  cases,  to  cleanly  denude  the 
scalp  of  hair,  for  at  least  four  inches  wide  of  our  line  of  inci- 
sion; because,  this  is  a substance  very  difficult  to  cleanse;  and, 
besides,  as  the  vascular  and  lymph  spaces  of  the  scalp  and 
dura-mater  are  continous  through  the  diploe,  in  the  event  of 
infection,  our  patient’s  life  is  placed  in  great  jeopardy.  As 
the  brain  in  all  these,  has  suffered  more  or  less  contusion,  the 
same  advantages  for  cocainization,  hold  good,  as  in  the  average 
skull  fracture. 

Local  cocainization  is  ample,  to  efficiently  deaden  sensa- 
tion, for  the  enucleation  of  chalazia,  or  fatty  tumors  of  the 
scalp. 

The  haemostatic  properties  of  the  alkaloid,  aid  in  produc- 


80  LOCAL  ANAZS  THE  TICS  AND  COCALNE  A NAL  CAZSIA. 

ing  an  anaemic  field;  so  that,  in  simple  growths,  with  narrow 
bases,  time  is  permitted  us,  to  turn  them  out  and  suture  the 
divided  edges  before  sensation  has  returned.  Notwithstand- 
ing, what  may  be  said  to  the  contrary,  it  is  my  practice  not  to 
disturb  the  surface  of  the  skull,  and  drill  through,  to  treat  a 
fracture,  unless  the  extent  of  depression  of  the  fragments  is 
considerable,  or  there  are  cerebral  symptoms  present.  But, 
this  is  not  the  place,  to  consider  the  controversional  side  of 
the  question. 

In  all  cases,  in  which  there  are  reasonable  grounds 
for  suspecting  fractures,  an  incision  will  do  no  harm,  and  in 
the  event  of  a litigation  following  the  injury,  we  are  able  to 
state  with  considerable  precision  the  exact  quality  of  the 
lesion. 

It  may  be  added  here,  parenthetically,  that  the  flat  bones 
of  the  skull  are  the  only  ones  in  the  body  which,  as  a rule, 
permit  of  an  incision  through  the  soft  parts,  for  purposes  of 
diagnosis  in  cases  of  fracture. 

By  hypodermication  here,  there  are  many  cases  in  which 
diagnosis  may  be  verified  which,  otherwise,  must  remain  in 
doubt.  Many  have  such  a deep-rooted  prejudice  against  pul- 
monary anaesthetics,  in  any  form,  that  they  will  rather  take 
chances  than  submit  to  their  administration.  But,  it  is  well 
to  remember,  that  though  the  technique  and  execution,  in 
the  major  part  of  those  exploratory  operations  on  the  skull, 
occupy  but  a few  moments,  yet,  in  every  case  the  most  minute 
particulars  must  be  observed,  in  our  preparations,  to  promptly 
staunch  hemorrhage  and  sterilize  the  parts. 

Local  anaesthesia  is  amply  efficient  in  certain  pathological 
conditions  of  the  skull  and  brain. 


C0CAIN1ZATI0N  IN  SCALP  AND  SKULL  INJURIES.  81 

In  those  large,  tedious,  trephine  operations,  undertaken 
to  dislodge  neoplastic  formations  within  the  skull,  a general 
anaesthetic  must  be  employed.  But,  to  deal  with  a limited, 
superficial  necrosis,  a traumatic  abscess  ol  the  brain,  located 
near  the  surface,  or  an  abscess  of  the  frontal  or  mastoid  sinus, 
we  now  possess  the  agent  to  deal  with  them,  which  renders 
general  anaesthesia  in  all,  but  exceptional  cases,  quite  unnec- 
essary. 

In  all  this  class  of  cases,  as  the  soft  parts  overlying  the 
seat  of  lesion  are  hyperaesthesic,  we  are  compelled  to  call  into 
action,  all  our  accessories,  in  the  way  of  chilled  surface- 
douching,  and  moderate  inebriation;  besides,  carry  our  dosage 
of  the  analgaesic  to  its  maximum,  before  we  attack  the  in- 
flammed  and  indurated  tissues. 


CHAPTER  XII. 


LOCAL  ANALGESICS  IN  THE  SURGERY  OF 
THE  FACE  AND  ITS  CONNECTING 
ORGANS. 


The  analgsesic  properties  of  cocaine  were  first  utilized 
in  ophthalmic  surgery,  and  here,  it  has  its  widest  limitations. 
Its  wide  range  of  application  in  the  ocular  region  is  fully  set 
forth,  in  all  modern  works  which  deal  with  this  special  branch 
of  the  healing  art;  and,  hence,  as  it  is  intended  here,  to  only 
deal  with  the  subject  as  it  concerns  the  general  surgeon  and 
family  practitioner,  it  will  be  referred  to  in  this  connection, 
only,  with  such  common,  simple  and  everyday- conditions,  as 
we  are  commonly  called  on  to  treat. 

As  an  aid  in  subduing  sensation  for  the  removal  of 
foreign  bodies  from  the  cornea,  cocaine  possesses  unrivalled 
power.  Its  action  in  this  locality  is  almost  instantaneous. 

Our  patient  comes  to  us  with  the  most  intense  orbicular 
spasm,  photophobia,  and  pain.  * A fragment  of  coal,  or  other 
hard  substance,  is  deeply  imbedded  in  the  cornea,  and  the 
eye  incessantly  rolls  on  its  axis  in  every  direction,  rendering 
it  quite  impossible  to  fix  it,  and  extract  the  foreign  body.  We 
separate  the  lids  and  instil  a drop  or  two  of  a four  per  cent, 
solution  of  cocaine;  when,  almost  at  once,  as  if  by  magic,  the 


—82— 


COCAIN/ZA 7 ION  IN  SURGERY  OF  THE  FACE. 


83 


whole  scene  is  changed;  our  patient  opens  the  lids,  and  fixes 
the  eyeball;  now,  as  senseless  to  pain  as  a dead  man’s. 

We  take  up  the  spud  or  needle,  and  with  as  much  leisure 
as  we  desire,  we  penetrate  the  epithelial  and  parenchymatous 
layers  of  the  cornea.  Though,  in  a dexterous  hand,  extraction 
is  but  the  labor  of  a moment,  the  analgaesic  lingers  a considera- 
ble time;  longer,  on  the  cornea,  it  has  seemed  to  me,  than  in 
any  other  tissue  of  the  body.  It  is  well  to  know  that  cocaine 
is  a powerful  mydriatic;  and,  along  with  annulling  sensation,  it 
at  once  paralyzes  the  accommodation.  Therefore,  it  is  always 
well  to  inform  our  patient  before  he  leaves  us,  that  his  vision 
may  remain  more  or  less  disturbed  for  some  hours. 

In  the  surgery  of  the  nasal  and  buccal  cavities  cocaine  dis- 
plays some  of  its  greatest  triumphs.  In  surgical  procedures 
on  the  periphery,  near  the  muco-cutaneous  junction,  at  the 
nasal  or  oral  portals,  it  is  simply  superb. 

Operations  on  the  borders,  or  within  the  nose  or  mouth, 
have  heretofore  been  a veritable  bete  noir. 

After  the  operator  passed  the  alveolar  arches,  his  difficul- 
ties commenced.  Space  for  manipulation  is  very  narrow,  the 
parts  are  extremely  vascular,  and  on  incision  of  the  tissues, 
blood  flows  in  every  direction,  choking  up  the  air  passages, 
draining  into  the  stomach;  besides,  it  covers  the  operative 
field.  In  vain,  the  surgeon  endeavors  to  mop  away  the  accu- 
mulating fluid. 

By  fits  and  starts,  the  patient  struggles,  vomits  and  blows 
the  streaming  current,  into  the  face  of  the  operator,  and  far 
away  over  the  walls  and  furniture. 

Necessarily,  in  nasal,  oral  or  labial  operations,  as  soon  as 
manipulations  are  begun,  when  pulmonary  anaesthetics  are 


84  LOCAL  ANAESTHETICS  AND  COCAINE  A A ALGESIA. 

employed,  the  ether  cone  must  be  removed.  Hence,  unless, 
the  operator  be  unusually  dexterous,,  skilled  and  rapid,  before 
he  can  complete  the  operation,  his  patient  is  coming  out  of 
ether;  perhaps,  at  just  that  stage,  when  absolute  quiesence  is 
imperative.  Now,  he  must  either  stop  here  and  leave  the 
operation  incomplete,  or  else  force  the  anaesthetic,  while  the 
patient  is  swallowing,  or  inhaling  blood  into  his  lungs  in  great 
quantities. 

But,  even  assuming  that  haemostasis  is  fairly  efficient, 
after  our  operation  is  complete,  when  undisturbed  rest  and 
efficient  asepsis  are  important;  as  soon  as  etherization  or 
chloroformization  is  over  (for  both  are  similar  in  this  respect), 
our  patient  becomes  halarious,  shouts,  screams  and  cries; 
besides,  in  most  cases,  has  free  emesis,  thereby  deranging  the 
wound  and  befouling  it  with  the  acrid  contents  of  the  stomach. 

Recently  an  endeavor  has  been  made,  to  overcome  some 
of  these  difficulties,  by  tapping  the  trachea  and  etherizing 
through  a cannula,  inserted  through  the  opening.  Leakage 
into  the  cervical  canals  is  prevented  by  stuffing  the  pharynx 
with  gauze.  This  scheme  lessens  the  dangers  of  infection  of 
the  wound  and  pulmonic  inflammation;  but,  it  adds  fresh  ones; 
for,  the  opening  of  the  trachea  is  no  trivial  affair;  and,  further, 
though  all  ultimately  succeed,  a stenotic  contraction  of  the 
windpipe,  with  an  impediment  in  the  voice,  is  almost  sure  to 
follow,  in  every  case. 

A few  years  ago,  since  cocaine  has  come  into  use  in 
surgery,  it  was  my  privilege  to  attend  the  clinic  of  one  of  the 
few  survivors  of  that  generation  of  great  operators  who  have 
pressed  far  to  the  front,  by  brilliant  achievements,  the  claims 
of  American  Surgery.  He  was  about  to  perform  an  operation 


COCAIN1ZA T10N  IN  SURGERY  OF  THE  FACE. 


85 


on  a middle-aged  man,  for  an  epithelioma  of  moderate  size, 
from  the  middle  of  the  lower  lip. 

Before  commencing  the  operation,  while  the  anesthetic 
was  being  administered,  he  warned  the  students,  that  in  oper- 
ations of  the  description  which  he  was  about  to  undertake,  it 
was  always  necessary  to  be  guarded  in  administering  an 
ansesthetic;  not  to  carry  it  to  full  narcosis;  but,  rather  carry  the 
patient  to  the  border  line,  only;  so  that,  should  the  escaping 
blood  accumulate  freely  in  the  mouth,  the  patient  would  be 
conscious  of  it  and  hawk  it  up;  thus,  in  that  manner,  prevent- 
ing its  entrance  into  the  air  passages,  and  a septic  pneumonia 
following. 

He  added,  that  in  that  class  of  operations,  danger  was 
rather  to  be  feared  from  this  source,  than  from  the  operation 
itself. 

That  admonition  was  timely  and  wholesome,  for  a by- 
gone age;  but,  in  our  time,  with  the  facilities  at  our  command, 
to  effect  complete  haemostasis,  and  temporarily  annul  pain 
over  local  areas,  it  was  quite  superfluous. 

Let  us  see  what  hypodermication  of  cocaine  can  do  to 
render  this  one  of  the  simplest  operations  in  surgery. 

First,  our  patient  is  cleanly  shaved,  and  the  lip  sterilized 
as  completely  as  possible. 

Next,  the  usual  quantity  of  alcoholic  fluids  are  given, 
while  preparations  for  the  operation  are  being  made.  When 
all  is  ready,  our  patient  is  placed,  sitting  in  a strong  arm-chair; 
and,  while  an  assistant  or  nurse  supports  the  head,  the  opera- 
tor proceeds. 

The  first  step,  is  to  carry  a strong  silk  suture  through, 
under  the  surface  of  the  angle  of  the  mouth,  from  within  out- 


86  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAES/A. 

* 

ward.  Now,  a small  pledget  of  lint  is  fixed  between  the  upper 
surface  of  the  lip  and  the  suture,  when  this  is  securely  fast- 
ened at  each  angle,  in  a sliding  knot.  Cocaine  solution  is  now 
injected,  according  to  the  general  rule  previously  set  forth. 
Our  operative  field  effectually  benumbed,  we  are  prepared  to 
proceed;  but,  let  us  pause  a moment,  and  consider  what  we 
have  accomplished  so  far.  Well,  we  have  shut  off,  with  our 
temporary  transfixon-ligature,  the  inferior-coronary-arteries, 
the  chief  nutrient  feeders  to  the  lower  lip.  At  the  same  time 
we  have  held  back  the  veinous  current;  and  therewith,  by  con- 
fining the  circulation,  intensified  the  action  of  the  cocaine. 
Accordingly,  we  have  practically  a dry  field  and  painless  sur- 
face, to  deal  with. 

This  stage  reached,  the  remainder  may  be  completed, 
without  any  assistance  at  all,  if  desirable.  There  our  patient 
sits,  looking  the  operator  in  the  face.  We  have  from  twenty 
to  thirty  minutes  now  to  perform  an  operation,  which  any  tyro 
should  go  easily  through  in  half  that  time.  There  will  be 
some  parenchymatous  oozing  of  the  blood,  but  no  spurting. 
As  the  blood  accumulates  in  the  mouth,  the  patient,  now  and 
then,  spits  it  into  a cuspidore,  pail,  or  whatever  is  most  con- 
venient. In  a few  moments  the  operation  is  completed. 
There  has  been  no  strangling,  struggling  or  vomiting. 

Dressings  are  applied,  when  qur  patient  rises  and  walks 
to  his  bed  or  ward,  or  goes  home,  if  he  wishes.  There  seems 
no  good  reason,  why  this  operation  should  not  be  performed 
in  one’s  office  in  mild  weather,  and  the  patient  allowed,  with 
an  attendant,  to  make  his  way  home,  after  he  has  had  a little 
rest;  for  the  shock  following  is  nothing,  compared  to  the  ex- 
traction of  a deep-rooted  tooth. 


COCAINIZA TION  IN  SURGERY  OF  THE  FACE. 


87 


Operations  Within  the  Buccal  Cavity. 

Hypodermication,  or  the  surface  application  of  cocaine, 
will  suffice,  for  any  description  of  surgical  intervention,  exter- 
nal to  the  pharyngeal  isthmus,  except  those,  which  involve  the 
osseous  and  dental  substance,  in  adults.  Perhaps,  an  excision 
of  the  tongue  may  be  an  exception,  though,  there  seems  no 
reason  why  it  should  not  succeed  here,  provided  the  operator 
is  rapid  in  execution,  and  complete  analgaesia  is  effected. 

Therefore,  in  all  adenoid  growths,  superficial  neoplastic 
formations,  urano-plastic  operations,  and  a great  variety  of  other 
pathological  conditions,  it  wholly  displaces  pulmonary  anaes- 
thetics, and  at  once,  renders  many,  hitherto,  very  bloody,  diffi- 
cuft  and  tedious  operations,  safe  and  of  easy  performance. 
The  experienced  laryngologist,  by  the  moderate  surface  appli- 
cation of  a four  per  cent,  solution  of  cocaine,  is  enabled  to 
readily  penetrate  and  explore  the  sinuous  recesses  of  the 
larynx;  painlessly  remove  vegetations  and  excrescences,  apply 
the  galvano-cautery,  or  other  therapeutic  agents. 

The  naso-pharynx  is  rendered  readily  accessible  to  manip- 
ulation, for  the  removal  of  surface  growths  and  treatment  of 
granular  inflammation  of  the  mucous  membrane. 

If  we  are  about  to  open  a post-pharyngeal  abscess,  or,  one 
lodged  in  either  tonsil;  a slight  mopping  of  the  surface,  about 
to  be  penetrated  by  the  lancet,  will  annul  all  pain-sense.  In 
urano-plastic  or  other  operations  on  the  palatine-vault,  local 
analgaesia  in  the  adult,  renders  these  comparatively  bloodless, 
and  greatly  reduces  the  difficulties,  in  the  way  of  their  per- 
formance. 

In  December,  1893,  a young  woman  was  sent  into  my 


88  LOCAL  ANAESTHETICS  AND  COCAINE  ANAL  GAeSLA. 

service  at  the  Harlem  Hospital  for  the  purpose  of  having  an 
operation  performed  on  her  palate.  On  examination,  it  was 
found,  that  she  had  a large  perforation  in  her  soft-palate; 
which,  was  of  such  extent,  that  it  would  nearly  admit  the  tips 
of  two  fingers.  She  confessed  to  having  had  syphilis.  This 
immense  hiatus  had  rendered  articulatiou  indistinct;  besides, 
gave  to  the  voice  a decided  nasal  twang,  so  that,  it  was  quite 
impossible  to  understand  her.  Along  with  this,  the  nasal 
secretions  were  constantly  falling  into  her  mouth;  and,  when 
she  ate  soft  food,  it  escaped,  through  the  breach  above,  into  her 
nasal  passage.  As  the  operation,  required  here  to  fill  this 
immense  hole,  would  require  an  extensive  and  cautious 
dissection,  besides  considerable  bleeding,  when  the  time 
for  it  arrived,  it  was  decided  that  pulmonary-anaesthesia 
must  be  necessarily  very  intermittant;  and,  as  the  danger  of 
sanguinous  leakage  into  the  trachea  was  imminent,  it  was  de- 
termined to  attempt  the  operation  without  any  sort  of  an  anaes- 
thetic. She  was  reconciled  to  bear  any  degree  of  pain,  pro- 
vided a hope  of  cure  was  held  out.  The  operation  was  under- 
taken at  a clinic,  in  the  presence  of  several  visiting  prac- 
titioners and  the  house  staff. 

Our  young  woman  was  possessed  of  marvellous  fortitude, 
and  bore  up  with  great  determination,  but,  in  spite  of  all  this,  as 
the  periosteum  of  the  palate  was  denuded,  when  the  bleeding 
points  were  pinched  up  by  the  clamps,  and  the  needle 
penetrated  sensative  areas,  the  head  was  involuntarily  jerked 
in  every  direction.  Thr  parts  were  terribly  vascular,  and,  with 
the  alternate  fits,  of  choking,  and  spasm  of  the  glottis,  she 
besmeared  every  one  about  her.  She  was  soon  seized  by  at- 


COCA  1N1ZA TION  IN  SURGERY  OF  THE  FACE. 


89 


tacks  of  syncope,  and  alarming  symptoms  of  prostration  set  in. 
The  operation  was  a humiliating  failure. 

The  best  that  could  be  done  was  to  secure  the  bleeding 
points,  and  leave  the  gap  unclosed.  Our  unfortunate  patient 
was  returned  to  bed. 

Every  day,  for  two  weeks,  the  mouth  was  rinsed  with  a 
peroxide  of  hydrogen  solution.  As  she  recovered  her  lost 
strength,  she  again  appealed  to  me  to  make  another  endeavor. 
After  having  again  carefully  studied  the  case,  we  decided  to 
once  more  make  an  effort,  to  remedy  the  defect,  by  another 
operation. 

Again  the  nasal  and  oral  cavities  were  carefully  sterilized; 
when  all  the  tissues  about  to  be  denuded  in  paring  the  borders 
and  for  flap-sliding,  were  first,  freely  injected,  with  a one  per 
cent,  solution  of  cocaine;  after  which,  the  surfaces  were  dried 
and  a four  pent,  solution  of  cocaine  freely  mopped  over  them. 
Now,  with  the  jaws  well  gagged  and  everything  in  readiness, 
operative  measures  were  begun.  The  transformation  scene 
after  this  species  of  analgaesia  was  adopted,  was  so  great  that 
one  who  was  not  a witness,  could  hardly  realize  it. 

Never,  in  any  region  of  the  body,  have  I seen  such  mag- 
nificient  results  from  the  action  of  this  truly  wonderful  agent. 
The  field  was  almost  free  from  hemorrhage. 

Never  did  I see  the  hemostatic  action  of  the  drug  more 
manifest  than  in  this  instance. 

The  extensive  mutilation  required,  to  obturate  the  large 
chasm  occupied  considerable  time;  all  the  while,  our  patient 
utterly  oblivious  of  the  least  twinge  of  pain. 

The  introduction  of  heavy  tension  sutures  was  a slow 
process,  in  the  very  narrow  cavity  of  the  mouth;  still  these — 


90  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGsESlA. 


seven  in  number,  and  twelve  fine  interrupted  sutures  through 
the  edges,  caused  no  pain  whatever.  This  time  success  at- 
tended every  stage  of  the  operation.  The  remainder  of  her 
history  is  very  simple  and  short.  She  was  placed  on  full 
doses  of  mercury,  and  the  parts  kept  clean. 

Union,  through  not  wholly  primary,  was  complete  in  the 
end,  and  she  left  the  hospital  with  the  palate  once  more 
whole,  three  weeks  after  the  last  operation. 

A litte  more  than  a year  ago,  a middle-aged  man  was  sent 
to  me  for  the  exciscn  of  a tumor  which  started  in  the  floor  of 
the  month,  a little  to  the  left  of  the  fraenum  linguae. 

It  was  explained  to  him,  that  as  it  occupied  a very 
vascular  region,  and  the  mouth  must  be  widely  opened  in 
operative  manipulation,  it  was  important  to  dispense  with 
ether,  and  rather  depend  on  cocaine.  He  was  very  timid,  and 
said,  that  he  was  informed  by  the  doctor,  rhat  he  would  be 
put  “asleep”  and  would  feel  nothing.  However,  after  a little 
persuasion,  he  yielded. 

In  this  cases,  but  35  drops  of  cocaine  solution  were  em- 
ployed. The  removal  of  the  growth  and  the  closing  of  the 
tissues,  in  which  it  was  imbeded,  were  so  quickly  accom- 
plished and  with  so  little  pain,  that  our  patient  would  not  be 
convinced  that  the  “lump”  was  out,  until  he  was  shown  it. 

In  this,  as  in  other  cocaine  operations  on  the  mouth,  the 
patient  is  always  placed  in  the  sitting  position,  before  a good 
light.  The  head  should  be  steadied  by  a nurse  or  attendant, 
though  the  patient  will  adjust  it  himself,  from  time  to  time,  in 
such  a manner  as  the  operator  indicates.  This  species  of 
analgsesia  will  not  succeed,  in  dental  surgery.  As  the  fangs  of 
a decayed  crown  are  always  imbedded  in  parts,  the  seat  of 


C0CAIN1ZATI0N  IN  SURGERY  OF  THE  FACE. 


91 


inflammation,  and  the  peridental  sheath  is  exquisitely  sen- 
sative;  that  the  deep  puncture  of  a hypodermic-needle  is 
attended  with  great  pain;  besides,  it  is  quite  impossible,  to 
reach  the  dental-nerve,  direct,  as  it  pierces  the  apex  of  the 
root. 

Caution  must  be  observed,  in  employing  cocaine  on  the 
nose  or  mouth,  because  of  their  close  contiguity  to  the  brain; 
and  the  reason  of  the  remarkable  power  which  the  mucous 
membrane,  lining  these  vaults,  posseses  for  absorption.  It  is 
seldom,  that  anything  more  is  required,  than  to  moderately 
swab  the  surface,  as  the  needle  need  not  be  employed,  unless, 
we  propose  to  attack  the  osseus,  or  submucous  tissues  of  the 
lips.  My  experience  with  the  employment  of  the  drug  on  the 
Schneiderian  membrane  is  limited  to  few  cases,  except  those 
of  epistaxis. 

In  those,  where  we  are  about  to  plug  the  passages,  for  a 
dangerous  nasal  haemorrhage,  if  we  will  first  analgise  the 
pharynx  and  lower  nasal  fossae,  by  a few  sweeps  of  a small 
sponge,  charged  with  the  solution  of  four  per  cent,  strength, 
it  will  render  our  manipulations  in  closing  the  -posterior  naris 
entirely  painless  and  devoid  of  spasm. 

Early  last  winter,  a boy  came  under  my  care  who  had  a 
small  exostosis  in  the  left  nostril,  which  so  closed  the  passage 
that  no  air  could  pass  through,  and  he  breathed  nearly  wholly 
through  the  opened  mouth.  The  mass  was  low  down,  so  that 
contact  with  the  surface  was  easy  and  instruments  could  be 
manipulated  without  difficulty.  The  nasal  passage  was  stuffed, 
for  a moment  or  two,  with  a moistened  sponge,  of  cocaine 
solution,  when  with  a strong  rougeur  the  defected  bone  was 
quickly  and  painlessly  torn  away. 


92  LOCAL  ANAZS  THE  TICS  AND  COCAINE  ANALGAES1A. 

The  rapidity  and  simplicity  of  this  operation  were  in 
stricking  contrast  with  two  other  rhinoplastic  operations,  with 
which  I had  been  previously  connected;  in  one  as  an  operator, 
and  in  the  other,  as  an  assistant. 

In  the  latter  case  I invited  in,  a specialist,  to  operate. 
The  patient  was  placed  under  full,  ether  narcosis.  Then  he 
was  operated  on,  lying  on  the  back.  He  had  a deflection  of 
the  fiasal-septum  which  blocked  one  of  the  nares.  The  opera- 
tor began,  by  making  an  incision  arround  the  border  ,of  the 
bulging  bone,  when  a bone  elevator  was  employed  to  separate 
the  mucous-membrane  from  the  septum.  This  was  a terribly 
bloody  procedure. 

The  patient  coughed,  vomited  and  struggled,  so  that  the 
chiseling  of  the  bone  was  attended  with  great  difficulty,  and 
when  the  projecting  piece  was  detached,  it  was  carried  by 
suction,  into  the  pharynx  and  swallowed.  It  was  fortunate 
that  it  did  not  enter  the  air  passages,  or  we  would  have  proba- 
bly lost  our  patient.  Ether  anaeesthesia  was  employed. 

In  February,  1893,  Dr.  W.  G.  Gaudineer,  of  this  city,  re- 
quested me  to  operate  for  him  on  a case  of  nasal  exostosis  of 
the  septum,  in  a young  man  of  nineteen. 

I strongly  urged  the  claims  of  cocaine  for  anaesthesia  here; 
but  in  vain,  for  neither  he  nor  his  parents  would  listen  to  me; 
but,  I warned  them,  that  this  would  be  a very  bloody  and  dif- 
ficult operation.  This  young  man  was  the  worst  case  I ever 
saw,  for  ether  anaesthesia.  In  fact,  it  was  quite  impossible  to 
anaesthetize  him,  at  all.  When  the  ether  was  pressed,  he  would 
be  seized  with  tetanic  spasms;  he  would  become  deeply 
cyanosed  and  cease  to  breathe.  He  took  nearly  a pound  of 


C0CA1N1ZA  TION  IN  SURGERY  OF  THE  FACE. 


93 


ether,  but  it  seemed,  that  nothing  would  control  the  violent, 
convulsive  struggling,  and  incessant  fits  of  sneezing. 

With  four  powerful  assistants  holding  him  down,  I was 
able,  to  go  hurriedly  through  the  operation,  but,  not  until  he 
had  bespattered  everything  with  blood;  far  and  near  him. 

This  case  was  an  ideal  one,  for  cocaine,  but  I was  over- 
ruled. I would  never  again,  consent  to  do  this  operation  with 
anything  other  than  cocaine,  as  an  anaesthetic;  unless  the  pa- 
tient after  being  acquainted  with  the  dangers  attending  pul- 
monary-anaesthesia, preferred  to  face  them. 


CHAPTER  XIII. 


LOCAL  ANALGESICS  IN  THE  CERVICAL 
REGION. 

Local  anaesthetics  serve  many  useful  purposes  in  the  tis- 
sues of  the  neck.  The  surgical  treatment  of  carbuncles,  situ- 
ated anywhere,  over  the  planes  of  the  spine,  is  always  very 
painful,  by  ordinary  measures. 

When  permitted  to  run  an  unrestrained  course;  or,  are 
dealt  with  by  means  formerly  in  vogue,  in  surgery,  they  are 
anything  but  inocuous  lesions. 

The  former,  routine  treatment  of  them,  consisted,  in  fully 
anaesthetizing  the  patient,  and  then  making  deep,  crucial  in- 
cisions into  them. 

As  they  are  always,  exquisitely  sensative,  full  ether  coma 
is  necessary,  in  order  to  fully  destroy  the  pain-sense,  to  the 
cutting  edge  of  the  scalpel,  so  it  divides  their  thickened,  indu- 
rated base.  Sometimes,  the  incision  is  attended  or  followed 
by  a large  haemorrhage;  just  at  the  time  when  the  patient 
can  least  afford  the  loss  of  blood.  Besides,  large,  open 
gashes  are  left,  which  augment  the  danger  of  infection,  in 
spite  of  any  antiseptic  precautions  that  may  be  observed. 

Now,  the  greater  part  of  these  cases,  after  suppuration 
has  commenced,  may  be  treated  by  injections  of  carbolic  acid 
reduced  by  heat,  to  a fluid  consistance. 

—94— 


C 0 CA INIZ  ATI  ON  IN  OPERATIONS  OF  THE  NECK.  95 


This  may  be  accomplished  by  the  direct  injection  into  the 
core  or  base,  in  four  or  five  places,  of  from  five  to  ten  drops  of 
this  solution.  These  injections  are  attended  with  a sense  of 
heat  at  each  puncture;  but  it  is  slight  and  soon  passes  off. 

The  effects  on  the  mass  are  immediate,  and  most  gratify- 
ing. The  extreme  agonizing  pain  is  promptly  assuaged  by 
the  anaesthetic  action  of  the  phenate,  formed  by  the  combina- 
tion of  the  acid  with  the  albuminous  elements  of  the  pus.  The 
anti-germicidal  action  of  the  acid  is  remarkable,  when  em- 
ployed in  this  manner.  As  the  fluid  is  injected  we  will  ob- 
serve that  the  surface  of  the  of  the  abscess,  loses  its  florid  hue, 
and  assumes  the  color  of  a part  that  has  been  recently  frost- 
bitten. These  injections  possess  the  dual  power  of  arresting 
pain  and  inflammatory  action. 

As  the  acid  in  this  pungent  saturated  form,  immediately 
chars  everything  it  comes  in  contact  with,  there  is  no  danger 
of  systemic  poisoning  following. 

The  injections  completed,  simple,  sterilized,  absorbent 
dressings  are  applied;  which,  are  permitted  to  remain  on,  until 
the  dry  mummified  slough  is  allowed  to  separate,  and  prolifer- 
ation of  healthy  granulations  has  well  advanced,  from  the 
bottom. 

This  procedure  is  safe,' simple,  painless  and  radical;  but, 
to  fully  realize  its  value,  one  must  try  it  on  those  cases,  in 
which,  other  painful  measures  have  failed. 

Dr.  J.  Goilav,  Surgeon  at  Bucharest,  Roumania,  has 
treated  twelve  cases  of  anthrax,  complicated  by  glycosuria, 
by  a somewhat  similar  plan,  (“Traitement  de  1’ Anthrax,  Journal 
de  Medicine  de  Bordeaux,  2 re  Oct.  ’93). 

He  first  injects  cocaine  solution  into  the  carbuncle,  and 


96  LOCAL  AN  AES  THE  TLCS  AND  COCALNE  ANALGAESLA. 

then  makes  a deep  crucial  incision.  Now,  he  fills  the  open- 
ing with  crystalized  boracic  acid.  Then,  a gauze  dressing  is 
applied,  under  a bandage,  and  allowed  to  remain  on,  twenty- 
four  hours.  The  pain  quickly  disappears,  the  temperature 
falls,  and  the  patient  sleeps. 

On  the  third  or  fourth  day,  the  dressings  are  again 
changed,  when  the  sphacelated  residue  is  sufficiently  detached 
to  permit  of  its  easy  removal.  It  was  seldom  found  necessary 
to  change  the  dressings  oftener  than  three  times,  and  as  a rule 
the  part  was  closed  in,  after  seven  or  eight  days.  He  adds, 
that  the  acid  gives  rise  to  no  painful  irritation;  nor,  is  it  ab- 
sorbed in  toxic  quantities;  and,  he  believes  that  this  plan,  is 
much  superior  to  all  others. 

It  is  interesting  to  note,  what  is  being  done  the  world 
over,  by  the  aid  of  cocaine;  but  in  carbuncle,  it  is  evident  that 
a drug  like  carbolic  acid,  which  is  a powerful  analgaesic 
and  caustic,  when  cases  are  suitable  for  it,  it  is  to  be  preferred 
to  boracic  acid;  particularly,  as  the  latter  always  entails  the 
use  of  the  scalpel,  and  displaces  the  alkaloid. 


CHAPTER  XIV. 


THE  SURGERY  OF  THE  ANTERIOR  AND  LAT- 
ERAL ASPECTS  OF  THE  NECK. 

The  contents  of  all  the  triangles  of  the  neck  from  the 
clavicle  to  the  ramus  of  the  lower  jaw,  lie  compara- 
tively superficial.  The  reason  that  these  exposed  region  are 
so  comparatively  immune  against  injury,  is,  because  of  the 
manner  in  which  they  may  be  instantaneously  protected,  by 
suddenly  raising  the  shoulders,  fixing  the  neck,  or  depressing 
the  head. 

I can  see  no  reason  why  we  cannot  ligate  all  the  arteries 
in  all  the  triangles,  painlessly,  with  the  aid  of  hypodermication. 

After  we  divide  the  platysma  and  push  the  various  sets  of 
muscles  aside,  we  come  at  once,  on  to  nearly  every  artery  in  the 
anterior  region  of  the  neck;  the  second  and  third  segments  of 
the  subclavian  as  well  as  those  vessels  of  minor  size  and  im- 
portance. However,  in  nervous,  irritable  excitable  individuals, 
it  would  be  better  to  rely,  on  a pulmonary  anaesthetic;  ex- 
cept, in  emergency  cases.  As  these  parts  are  highly  vas- 
cular and  constitute  the  connecting  bond  for  the  blood  sup- 
ply between  the  heart  and  brain,  a skilled  and  very  cautious 
dissection  is  demanded  in  all  cases. 

If  our  patient  is  restless  and  insubordinate,  every  move 
will  be  attended  with  peril. 


—97— 


98  LOCAL  ANAESTHETICS  AND  COCAINE  aNALGaESLA. 

Should  the  vessels  pursue  an  abnormal  course  and  be  cut 
across  with  the  scalpel,  our  patient  might  be  suddenly  seized 
with  terror  and  become  unmanageable,  just  at  the  time  when 
the  loss  of  one  minute  might  cost  a life. 

Therefore,  unless  the  circumstances  are  of  an  unusual 
character,  no  skilled  assistants  are  to  be  had,  and  the  case 
will  not  admit  of  delay,  we  should  not  interfere  without  first 
placing  our  patient  under  full  ether  anaesthesia. 

With  neoplastic  formations  of  small  size,  superficially 
located  and  freely  movable  we  may  fare  better  with  cocaine- 
analgaesia. 

By  this  procedure,  in  many  of  those  adenoid  growths  of  a 
tubercular  character,  when  involving  only  the  superficial  chain 
of  lymphatics,  we  may  succeed  in  removing  them  with  great 
ease  and  rapidity.  The  same  may  be  said,  of  small  cystic 
growths  on  the  periphery  of  the  thyroid  gland.  In  cases  of 
parenchymatous  hypertrophy  of  one  or  both  lobes  of  the  thy- 
roid gland  which  dangerously  compress  the  trachea  it  will  not 
succeed,  so  well. 


CHAPTER  XV. 


COCAINE-ANALGESIA  IN  ADULT 
TRACHEOTOMY. 


In  the  average  text-book  on  surgery  the  operative  tech- 
nique of  tracheotomy  is  considered  in  such  a matter  of  fact, 
manner,  that  the  inexperienced,  average  reader  is  led  to 
believe,  that  it  is  an  operation  simple  and  easy  of  perform- 
ance; but,  when  one,  however,  proceeds  to  perform  it,  without 
proper  preparation  and  a full  knowledge  of  the  dangers  which 
often  beset  him,  by  the  older  methods,  he  will  be  woefully  mis- 
taken, as  to  its  simplicity  or  safety. 

The  older  Gross  taught,  that  it  was  one  of  the  most  diffi- 
cult operations  in  surgery. 

When  we  recollect  the  great  depth  at  which  the  rings  of 
the  trachea  are  placed  in  certain  individuals,  that  the  upper 
part  of  the  trachea  is  snugly  embraced  by  the  thyroid  gland; 
that  it  is  crossed  and  re-crossed  by  a large  plexus  of  veins,  that 
it  is  always  in  motion,  and,  in  stridulous  breathing  it  is  pulled 
deeply  down  into  the  thorax,  with  each  inspiration,  we  may 
the  better  appreciate  some  of  the  difficulties,  attending  the 
opening  of  it. 

The  opening  of  the  healthy  trachea  is  a comparatively 
simple  procedure;  but,  when  any  part  of  the  air  passages  is 


-99— 


100  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAS1A. 

the  seat  of  stenosis  and  the  patient  has  to  struggle  for  breath, 
it  is  quite  another  matter. 

In  the  latter  condition,  the  administration  of  pulmonary 
anaesthetic,  in  many  cases,  so  embarrasses  respiration,  as  to 
threaten  mortal  suffocation. 

A few  of  the  most  formidable  difficulties  may  be  better 
understood  by  the  citation  of  a case  or  two,  and  then  contrast- 
ing the  difference  of  operating  by  the  older  and  the  more 
modern, — the  easier  and  the  safer  methods. 

About  ten  years  ago,  I was  hastily  summoned  in  the  night 
to  see  a man,  who  the  messenger  said,  was  suffocating.  Pick- 
ing up  my  pocket  case,  I hurried  to  the  house  of  the  dying 
man.  There  I found,  that  the  patient  had  got  up  during  the 
night  to  take  a drink  of  oatmeal  water,  when,  through  mistake, 
he  took  a pitcher  which  contained  water  and  slaked  lime.  He 
agitated  the  pitcher,  then  raised  it  to  his  mouth,  and  took  two 
or  three  swallows,  before  he  discovered  his  mistake.  He  was 
immediately  seized  with  an  intense  burning  in  the  larynx,  and 
great  difficulty  in  breathing. 

When  I saw  him  he  lay  on  the  floor  in  deep  cyanosis;  the 
pulse  at  the  wrist  was  uncountable,  and  he  was  making  the 
most*  desperate  efforts  to  get  his  breath.  I at  once  saw  that 
he  had  acute  oedema  of  glottis,  and  that  the  windpipe  must  be 
opened  on  the  spot,  without  any  preliminaries,  or  all  was  lost. 

With  an  old  woman  holding  a candle,  I fully  extended 
his  head,  felt  for  the  trachea  and  plunged  the  blade  of  the 
scalpel  into  it,  with  the  cutting  edge  upward,  carrying  it  through 
the  cricoid  cartilage.  Now  blood  came  in  a deluge  through 
the  nose  mouth  and  wound  simultaneously.  Everything  was 


C O CAINIZA  TION  IN  TRA  CHE  OTOMY. 


101 


spattered  about  him,  by  the  first  few  violent  coughs  and 
spasms,  which  followed  the  incision. 

For  a moment  the  loss  of  blood  was  terrible. 

As  there  was  practically  no  light  to  enable  me  to  see  the 
bleeding  points,  I felt  for  the  cut  edges  of  the  wound  and 
compressed  each  side,  between  the  nails  of  the  index  finger 
and  thumb  of  each  hand.  The  pressure  maintained  for  a few 
moments,  stopped  the  bleeding  and  gave  me  time  to  insert  a 
few  deep  sutures  on  each  side  and  retract  the  edges  until  a 
tube  could  be  secured.  Within  twenty-four  hours  the  oedema- 
glottidis  had  passed  away,  and  in  a short  time  be  made  a good 
recovery. 

A case  was  brought  into  my  service,  in  the  Harlem  Hos- 
pital, four  years  ago,  of  a man  who  was  injured  in  the  neck,  by 
a loaded  express  wagon  passing  over  it.  He  had  sustained 
injuries  of  the  spine  and  larynx.  At  first  it  was  thought  that, 
difficulty  in  phonation  and  breathing  were  attributable  to  in- 
jury of  the  recurrent  laryngeal  nerves;  but,  as  swelling  soon 
followed,  with  chills  and  rise  of  temperature,  it  was  evident 
that  the  peri-laryngeal  tissues  and  vocal  cords  had  sustained 
damage,  and  might  at  any  moment  threaten  life,  by  obstruct- 
ing the  air-passages. 

It  was  advised  that  a tracheotomy  should  be  performed, 
when  he  was  seen  by  me  a second  time;  but,  he  preferred  to 
take  chances  and  wait.  In  the  meantime  the  house  surgeon 
was  directed  to  be  on  the  alert,  and  immediately  open  the 
trachea,  should  imminent  symptoms  of  laryngeal  stenosis  set 
in. 

On  the  evening  of  the  third  day,  symptoms  of  suffocation 
suddenly  developed;  but,  the  house  surgeon,  now  fully  realiz- 


102  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

ing  many  of  the  difficulties  in  the  way,  failed  to  perform  the 
tracheotomy  and  sent  for  me. 

At  this  time  our  patients  condition  was  desperate.  The 
picture  he  presented,  in  his  agony,  for  breath  was  something 
dreadful  to  behold.  His  voice  was  now  entirely  gone,  and  he 
would  only  whisper  in  gasps;  all  the  while,  the  shoulder  rising 
high  with  each  respiration.  All  the  auxiliary  muscles  were 
called  into  play,  and  the  whole  body  was  agitated. 

My  first  efforts  in  the  way  of  relief,  were  directed  towards 
canalizing  the  larynx,  through  the  mouth,  with  an  O’Dwyer 
tube.  But,  I now  learned  the  practical  lesson,  that  intubation 
in  the  young  child  and  the  adult,  is  not  quite  the  same  thing. 
In  fact,  a tube  of  a size  corresponding  to  age  and  difference,  in 
proportions  of  the  body,  cannot  be  inserted  at  all,  in  certain 
adult.  As  age  advances  in  the  growing  youth,  the  base  of  the 
pharynx  sinks  deeper  and  deeper. 

In  the  young  child,  we  may  readily  feel  the  edge  of  the 
epiglottis,  which  is  the  most  important  guide  to  the  intubator. 

But,  in  the  adult  the  rima-glottidis  is  on  a level  with  the 
superior  surface  of  the  sixth  cervical;  while  in  early  life,  it  lies 
on  a plane  with  the  inferior  surface  of  the  body  of  the  fourth 
cervical  vertebra.  Hence,  in  the  adult,  this  valuable  guide  is 
wanting;  and  the  necessary  circular  sweep  cannot  be  easily 
made,  in  the  hollow  of  the  pharynx.  Therefore,  it  is  only,  by 
a specially  constructed  apparatus,  manipulated  by  an  expert, 
that  intubation  is  possible  at  all,  in  the  adult,  under  ordinary 
circumstances.  Indeed,  I have  been  informed  of  a case,  in  which 
one  of  the  most  emminent  living  intubators,  only  after  many 
protracted  efforts,  finally  lodged  the  tube.  But  post  mortem 


COCAINIZA TION  IN  TRACHEOTOMY. 


108 


examination  showed,  that  it  had  been  merely  fixed  in  the 
oesophagus,  behind  the  cricoid  cartilage. 

I have  made  many  and  repeated  experiments  on  the 
cadaver,  to  determine  the  practicability  of  adult  intubation; 
devising  for  this,  instruments,  of  various  forms.  All  of  which 
convinced  me  that  adult  intubation,  as  a current  operation  is 
quite  impracticable,  and  with  the  expert,  is  always  attended  with 
difficulties.  With  our  patient,  as  might  have  been  expected, 
all  our  efforts  at  intubation  were  futile,  and  we  hastily  pre- 
pared for  tracheotomy. 

Now,  with  four  assistants,  excellent  light,  and  a complete 
arsenal  of  surgical  instruments,  and  two  trained  nurses  to 
prepare  sponges,  and  attend  to  other  details,  I was  impressed 
with  a sense  of  confidence,  that  the  way  was  clear  to  trache- 
otomize,  without  any  immediate  danger  to  life. 

But  our  troubles  commenced  with  the  preliminaries  of 
the  operation;  for,  with  the  first  whiffs  of  ether,  violent 
spasms  of  the  glottis  set  in,  and  for  a moment  the  pulse  at  the 
wrist  was  lost.  The  windows  were  thrown  widely  open,  and 
by  resorting  to  artificial  respiration,  he  commenced  to  breathe 
again. 

It  was  now  thought  that  by  the  substitution  of  chloroform 
there  would  be  less  laryngeal  irritation;  which,  was  the  case, 
but  in  a moment  he  went  into  syncope,  and  breathing  stopped 
altogether. 

By  forcible  artificial  respiration,  in  a moment  or  two  the 
lungs  commenced  to  act,  and  he  was  rapidly  regaining  con- 
sciousness. At  this  juncture,  while  forcibly  held  on  the  table, 
with  the  head  well  flexed  over,  on  the  cervical  spine,  backward, 
the  tissues  over  the  trachea,  which  was  deeply  lodged,  were 


104  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGASIA 

divided.  As  the  thyroid  isthmus  was  bisected,  the  blood  issued 
up  through  the  wound,  in  one,  large,  continuous  torrent. 
Because,  of  the  site  of  its  source,  pressure  was  impracticable, 
and  as  it  seemed  to  come  from  every  direction,  the  secure 
clamping  of  all  the  bleeding  orifices  was  a very  tedious 
process;  hence,  as  soon  as  the  nude  rings  of  the  trachea  came 
into  sight,  the  point  of  the  scalpel  was  introduced,  and  it  was 
freely  opened.  Some  of  the  blood  now  passed  into  the  trachea; 
when,  he  was  seized  with  a violent  spasm  of  all  the  muscles; 
which  lasted  for  a moment,  and  the  respiration  ceased.  The 
eyes  rolled  in  their  sockets,  the  cyanosis  deepened,  a frothy 
fluid  issuid,  through  the  mouth  and  nose,  when  it  seemed,  sure 
enough,  that  he  was  dead.  But  a large  tracheal  tube  was 
quickly  inserted,  artificial  respiration  was  promptly  instituted, 
and  after  working  on  him  for  five  minutes,  he  gave  a gasp; 
which  was  succeeded  shortly  after  by  another,  and  in  a short 
time  complete  resuscitation  was  established.  His  ultimate 
recovery  was  rapid,  and  he  has  since  remained  well,  except, 
for  the  stenosis  following  the  operation  of  tracheotomy. 

Five  years  ago  the  late  Dr.  W.  W.  Dawson,  of  Cincinnati, 
presented  a brochure  at  the  Annual  Meeting  of  the  American 
Medical  Association,  in  Newport,  R.  I.,  entitled  “ Tracheotomy 
By  a Bloodless  Method." 

This  eminent  Western  Surgeon,  in  eloquent  and  forcible 
terms,  set  forth  the  manifold  difficulties  which  commonly 
beset  the  operator,  in  the  performance  of  tracheotomies.  He 
maintained,  that  the  most  formidable  obstacle  to  overcome, 
was  hemorrhage;  that  the  loss  of  blood  jeopardized  in  two 
ways;  first,  by  exsanguination,  when  the  loss  was  great;  and 
secondly,  by  the  escape  of  blood  into  the  trachea. 


C0CA1NIZA T10N  IN  TRACHEOTOMY. 


105 


Therefore,  if  haemorrhage  could  be  sufficiently  subdued, 
before  the  trachea  was  opened,  the  operation  was  stripped  of 
one  of  its  greatest  dangers. 

This  contribution  was  soon  followed  by  Reclus’  exhaus- 
tive essay  on  the  “Surgical  Therapy  of  Cocaine  Analgaesia.” 
( Gazette  Hebdomidaire,  12  Mai , 1889). 

It  occurred  to  me,  that  if  we  could  combine  the  bloodless 
with  the  painless  method,  our  surgical  procedure  for  trach- 
eotomy, would  have  nearly  approached  the  ideal. 

Pulmonary  anaesthetics  could  be  cast  aside,  our  patient 
might  be  operated  on,  in  that  position,  which  would  give  us 
the  greatest  facility  for  manipulation. 

But,  so  many  things  in  our  profession,  when  presented  to 
us  by  the  master  hand  of  the  word-painter,  are  supported  by 
such  apparent,  sound  reasoning  and  logic,  that  theoretically, 
we  at  once  accept  them;  though,  when  we  put  them  into  prac- 
tice, their  fallacious  foundation,  at  once,  becomes  apparent, 
and  we  contemptuously  cast  them  aside;  perhaps  as  worse,  than 
useless. 

In  the  winter  of  1889,  a middle-aged  woman  was  sent  in, 
to  my  hospital  service  for  tracheotomy.  She  was  suffering 
from  agonizing  spells  of  dyspnoea,  from  laryngeal  spasm,  caused 
by  progressive,  tubercular  ulceration  of  the  vocal-cords. 

She  was  greatly  emaciated  and  in  broken  spirit,  because 
her  malady  was  making  steady  headway,  and  now,  her  con- 
stant fear  of  suffocation  kept  her  continually  awake.  Her 
voice  was  lost,  and  even  a whisper  was  only  uttered  with 
great  labor.  This  seemed  to  me  an  ideal  case  to  try  what 
I have  designated  the  “Reclus-Dawson  method,”  or  the  Dry 
and  Painless  procedure. 


106  LOCAL  ANAESTHETICS  AND  COCAINE  ANaLGMSJA. 

Our  patient  was  well  stimulated  with  the  alcoholics,  the 
parts  prepared,  and  cocainization  begun. 

Sixty-five  drops  were  injected  through  four  hubs. 

Now,  with  a half  dozen  clamps,  scissors  and  a dull  scal- 
pel in  readiness,  the  incision  over  the  larynx  was  commenced. 
After  the  integument  and  superficial  fascia  were  divided,  the 
remainder  of  the  dissection,  down  to  the  trachea,  was  made 
rather  by  tearing  through  the  parts,  than  cutting.  In  this 
manner  of  dividing  the  vessels,  but  little  blood  was  lost,  and 
in  a few  moments,  fully  an  inch  of  the  bare  tracheal  wall  came 
into  view. 

When  all  oozing  had  ceased  and  we  had  a clean,  dry 
incision,  the  trachea  was  opened  freely,  and  a tube  slipped 
through  the  opening.  The  operation  had  been  successful  in 
every  particular.  There  was  no  pain  of  any  kind  borne.  We 
had  an  anaemic  field,  no  struggling,  strangling,  nor  vomiting. 
The  relief  to  our  patient  was  great. 

After  dressings  were  applied,  and  she  was  placed  in  bed, 
she  had  twelve  continuous  hours  of  sleep.  She  remained  with 
us  a month,  making  rapid  improvement  in  her  general  con- 
dition, gaining  flesh,  strength  and  courage.  Since  she  left, 
we  have  had  no  further  tidings  of  her. 

December,  1892,  a lady  called  on  me  to  see  her  baby,  four 
months  old.  The  little  one  for  two  weeks  previously  had  been 
ill,  suffering  from  a croupous  state  of  breathing.  The  child 
was  unable  to  nurse,  and  had  great  difficulty  in  swallowing. 
Her  family  physician  recommended  intubation,  but  as  her 
sister  had  had  two  children  intubated,  that  died  with  the 
tubes  in,  she  demurred.  The  clinical  history  of  the  case  and 
the  child’s  condition  assured  me,  that  she  was  not  suffering 


COCAINIZA TION  IN  TRACHEOTOMY. 


107 


from  any  ordinary  disease  of  infancy,  of  an  inflammatory 
character;  but  rather  from  some  description  of  a new-growth,  or 
an  abscess. 

I mentioned  cocainization  to  the  mother,  as  a painkiller 
in  operating;  for  I had  recommended  an  immediate  trache- 
otomy; but,  she  feared  that  the  little  one  might  suffer,  and 
would  prefer,  that  ether  would  be  first  tried. 

In  the  afternoon  of  the  same  day,  an  operation  was  under- 
taken with  ether;  but,  alarming  cyanosis  set  in  at  once,  with 
the  first  inspiration,  and  it  was  laid  aside.  The  baby  quickly 
recovered  consciousness. 

Now,  six  drops  of  a one  per  cent  solution  of  cocaine 
were  injected,  and  Dawson’s  bloodless  tracheotomy  performed. 

When  the  trachea  was  opened,  a probe  was  pressed 
upward,  through  the  larynx,  when  an  abscess  was  bursted, 
which  drained  out  through  the  tracheal  incision.  No  tracheal 
tube  was  employed.  But,  the  edges  of  the  divided  tube  were 
widely  separated,  by  strong,  silk  sutures,  which  went  around 
the  neck,  in  opposite  directions,  and  were  tied  behind.  This 
expedient  answered  admirably.  Indeed,  I am  quite  certain  in 
a large  number  it  is  much  safer  and  more  satisfactory  than  any 
sort  of  a tube. 

In  any  case,  it  is  difficult  to  secure  a tube,  which  properly 
fits;  that  is  not  too  large  or  too  small;  in  which  event,  it  is 
worse  than  useless.  The  after-treatment  on  this  case  was 
simple;  recovery  was  prompt;  and,  in  ten  days  the  tracheal  in- 
cision had  closed. 

Cocainization  should  totally  supplant  every  description  of 
pulmonary  anaesthetics;  both  in  acute  and  chronic  stenosis  of 
the  larynx,  in  the  adult,  and  in  infancy  or  childhood,  when 


108  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

volatile  agents  greatly  augment  the  dangers  of  operation. 

Combined  with  efficient  haemostasis,  it  renders  safe  and 
comparatively  simple,  an  operation  heretofore  regarded  as  one 
of  the  most  difficult  and  dangerous  in  surgery. 


CHAPTER  XVI. 


LOCAL  ANALGESICS  IN  THE  SURGERY  OF 
THE  UPPER  EXTREMITIES. 

The  number  of  pathological  conditions  in  the  extremeties, 
which  may  be  safely,  painlessly  and  promptly  operated  on  by 
cocainization,  is  very  large  and  ever  growing. 

In  certain  respects,  these  pendant  members  of  the  body, 
present  advantages,  foreign  to  other  parts;  though,  withall, 
are  not  quite  satisfactory.  In  the  first  place,  by  utilizing  Dr. 
Leonard  Coming’s  method  of  applying  a firm  elastic  band, 
anywhere  above  the  point  at  which,  we  are  about  to  insert  the 
needle,  we  retard  the  entrance  of  the  alkaloid  into  the  general 
circulation,  and  can  prolong  its  local  action.  However,  this 
advantage  is  not  as  great  as  it  seems,  and,  after  all  may  be  one 
of  questionable  value,  in  any  other,  than  rare  and  exceptional 
cases. 

As  cocaine-analgaeesia  properly  effected  will  continue 
thirty  minutes,  it  may  be  a question  whether  or  not,  the  tissues 
can  safely  bear  constriction  and  total  arrest,  of  the  circulation, 
over  a longer  period.  There  are  few  operations  suitable  for 
cocainization,  which  cannot  be  completed  within  the  limit  of 
half  an  hour. 

In  any  event,  when  we  are  about  to  perform  an  operation 
which  will  entail  a considerabld  loss  of  blood,  we  will  apply 


—109— 


110  LOCAL  ANAESTHETICS  AND  COCAINE  AAALGsESIA. 

the  rubber-bandage,  and  keep  it  on,  until  haemostosis  is  com- 
plete. But,  the  muscular  substance  and  the  impenetrable 
osseus  tissue  are  quite  immune  to  cocainization;  hence,  the 
reason  why  we  cannot  utilize  it  always  with  advantage,  through 
any  part  of  the  upper  or  lower  extremeties,  in  amputations, 
except  those  of  the  digits. 

Since  this  monograph  has  commenced  to  run  through  the 
press,  I have  been  favored  with  a highly  valued  communication, 
on  the  use  of  cocaine  in  the  major  amputations,  from  Dr.  R. 
H.  Cowan,  of  Radford,  Va.:  He  says  * * * 

“Within  the  last  twelve  months,  I have  ventured  farther, 
and  performed  several  more  serious  operations  with  cocaine 
as  my  anaesthetic,  and  in  every  instance,  its  action  has  been  all 
I could  desire.  Anaesthesia  has  been  perfect,  no  bad  symp- 
toms have  occurred,  and  union  by  first  intention  has  been  the 
rule. 

“The  operations  have  been  as  follows:  A large  and  deep- 

ly imbedded  tumor  (adipose),  removed  from  the  popliteal  re- 
gion, and  seven  amputations — four  of  the  leg,  and  one  each,  of 
the  thigh,  forearm  and  arm. 

“Cocaine  was,  I believe,  first  advised  in  amputations  by 
Dr.  Corning,  and  his  advice  was  strengthened  by  an  actual  ex- 
perience. Why,  he  has  not  had  more  followers,  I do  not  know; 
it  is,  however,  for  this  very  reason,  that  I am  induced  to  con- 
tribute my  early  experience.  I am  well  aware,  that  we  have 
reports  of  disastrous  results  from  cocaine,  nor  would  I coun- 
tenance the  reckless  administration  of  a drug,  with  whose 
properties  we  are,  as  yet,  but  little  acquainted.  Whether  or 
not  cocaine  will  supersede  ether  and  chloroform,  in  the  near 


C 0 CAINIZA TION  IN  SURGERY  OF  THE  EXTREMITIES.  Ill 


future,  I cannot  say;  but,  believing,  that  it  is  only  by  reports, 
from  actual  experience,  that  we  can  arrive  at  any  definite 
knowledge  of  its  virtues,  I desire  to  contribute  my  mite. 

“Before  concluding,  I may  mention  some  of  the  advan- 
tages, which,  it  seems  to  me,  are  secured  by  the  use  of  cocaine: 
“].  Absence  of  depressing  effects,  in  cases  of  severe 
shock,  or  of  constitutonal  weakness. 

“2.  Freedom  from  nausea,  and  vomiting  after  operations. 
“3.  Limitation  of  anaesthesia  (of  course  construction  with 
an  Esmarch  above  point  of  operation  is  made)  to  the  field  of 
operation,  and  consequent  comparative  security  from  fatal 
narcosis. 

“In  the  above  mentioned  operations  (with  the  exception 
of  the  first  two  amputations)  I have,  at  the  suggestion  of  Dr. 
Wythe,  employed  a 2 % solution.  This  strength,  while  proving 
equally  or  perhaps  more  efficient,  in  producing  anaesthesia, 
possesses  the  additional  sdvantage,  of  reducing  to  a minimum, 
the  danger  of  any  toxic  effect.” 

In  answer  to  enquiry,  as  to  particulars,  the  doctor  has  very 
kindly  informed  me,  that  he  has  used  from  half  an  ounce  to 
two  ounces  in  major  amputations,  as  of  the  upper  third  of 
the  leg  and  the  thigh.  He  at  first  used  a four  per  cent,  solu- 
tion, and  later  a two  per  cent.  After  his  injections  are  finished, 
he  kneads  the  integuments  well,  and  waits  from  five  to  ten 
minutes  before  making  the  severance,  through  the  continuity 
of  the  limb.  He  always  employed  the  Corning  elastic  band. 
All  the  doctor’s  cases  were  males.  He  gave  a moderate  dose 
of  whiskey  before  commencing  operation.  He  has  observed 
no  bad  results,  from  the  use  of  cocaine,  either  locally,  or 
otherwise,  for  all  his  patientr  made  good  recoveries.  He  has 


112  LOCAL  ANAESTHETICS  AND  COCAINE  ANAL  GALS  LA. 

performed  two  more  leg  amputations,  since  his  first  note  came 
to  me,  now  making  four  amputations  of  the  leg,  one  of  the 
thigh  and  one  af  the  forearm,  all  recovering. 

Since  Dr.  Cowan  commenced  cocainization  as  a general 
analgaesic  for  amputations,  Dr.  Charles  E.  Peyton,  of  Roanoke, 
Va.,  has  performed,  with  the  happiest  results,  an  amputation  of 
the  leg,  with  this  agent. 

Dr.  R.  H.  Cowan,  says,  he  should  he  given  the  full  credit 
-of  introducing,  on  a large  scale,  the  use  of  cocaine,  as  an 
analgaesic,  in  major  amputations,  in  America,  as  a general 
practice,  and,  in  all  cases,  saving  his  patients. 

Cocainization  usually  serves  an  admirable  purpose  in 
finger  or  toe  amputation,  in  whitlows;  in  surgical  necrosis  of 
the  finger-bones;  in  tenotomy,  or  dissection  for  Dupuythren’s 
contracture,  and  other  conditions,  demanding  the  division  of 
the  tissues  of  the  body.  As  the  hand,  and  the  foot,  too,  on 
its  open  surfaces,  over  both  the  fingers  and  toes,  are  covered 
by  a dense,  tough  felting  of  integument,  the  penetration  of 
the  hypodermic  needle  is  painful  and  difficult.  In  fact,  this 
constitutes  the  greatest  objection  to  hypodermication  here; 
for,  sometimes  these  punctures  are  as  painful  as  incisions  in 
these  vicinities. 

In  the  neighborhood  of  the  radio-carpal  articulation,  thecal 
cysts,  or  bursae  are  frequently  seen;  and  especially  on  the 
dorsal  aspect  of  the  wrist.  Very  often,  their  situation  and 
their  origin,  as  suspected  from  their  physical  characters,  are 
very  deceptive.  They  usually  seem  to  lie  immediately  under 
the  skin,  are  quite  mobile  and  give  the  impression  of  having 
no  very  deep  attachments. 


C0CA1NIZA  TION  IN  SURGERY  OF  THE  EXTREMITIES.  113 


Many  an  unwary  practitioner  has  come  to  trouble,  by  an 
attempt  to  remove  these,  by  incision.  Several  years  ago,  I 
assisted  in  the  attempt  to  remove  one  of  these  innocent-look- 
ing bodies.  On  dissection,  the  thin  cyst-wall  ruptured,  and  it 
was  found,  that  its  base  was  continuous  with  the  tendon  of  the 
supinator-longus  muscle. 

The  most  violent  inflammatory  reaction,  with  deep-seated 
inter-muscular  inflammation  followed;  which  required  many 
deep  incisions  to  evacuate  the  pus-formation.  The  general 
suffering  was  great  and  long  continued.  Finally,  when  sup- 
puration ceased,  considerable  and  painful  anchylosis  of  wrist- 
joint  and  fingers  remained.  This  made  me  cautious  of  ever 
attempting  anything  more  for  these  cases,  than  by  palliative 
measures. 

Lister’s  doctrine  of  antiseptics  was  an  attractive  one,  when 
we  were  assured,  that  with  the  riged  application  of  antiseptic 
agents,  inflammation  after  operations  might  be  often  pre- 
vented. My  early  experience  lead  me  to  support  that  view, 
though  it  was  not  long,  before  I was  thoroughly  convinced  that 
it  was  not  faultless;  and  that  on  the  contrary,  when  chemical 
solutions  are  employed  on  any  of  the  serous  membranes,  or 
the  bones,  they  are  often  followed  by  a most  pernicious  type 
of  inflammation. 

A young  school  teacher  was  sent  to  me,  by  Dr.  Geo.  D. 
McGauran,  suffering  from  a very  painful  bursa,  which  was 
situated  near  the  styloid-process  of  the  radius  on  the  right 
wrist.  Her  hand  was  so  crippled  by  it,  that  she  was  unable  to 
hold  a pen  in  writing;  besides,  it  had  become  very  painful. 

Bandage  pressure,  painting  with  tr.  of  iodine,  and  lini- 
ments had  been  used,  without  benefit.  Finally,  the  doctor 


114  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGaESIA. 

advised,  that  she  have  it  cut  out.  At  this  time  antiseptic-treat- 
ment of  wounds  was  in  full  blast,  and  we  had  come  to  regard 
no  region  of  the  body,  as  outside  the  domain  of  surgery. 

This  young  lady  was  advised,  however,  of  the  possible 
danger  of  post  operative  inflammation.  She  avowed  herself 
ready  to  take  the  chances;  saying,  that  she  could  be  scarcely 
worse  off,  than  she  was  then,  with  a crippled  hand. 

Under  the  strictest  antiseptic  precautions,  this  bursa  was 
exposed  and  raised  unbroken,  into  the  incision.  It  was  then 
opened  slightly  at  its  apex,  and  a small  probe  introduced, 
which  passed  at  once  into  the  thecal  sheath  of  the  tendon  of 
the  extensor-proprius-pollicis.  Now,  a fine  cat-gut  ligature 
was  thrown  around  its  base  and  tightly  secured,  when  the  body 
of  the  cyst  was  cut  away,  with  scissors. 

The  usual  dressings  were  applied,  and  the  whole  hand 
and  fore-arm  fixed  in  splints,  and  suspended  in  a sling.  But 
with  all  our  care,  sharp  inflammatory  reaction  followed.  Ice- 
cloths  were  continuously  applied  over  the  wrist  for  four  days, 
and  opium  had  to  be  freely  employed  to  relieve  pain.  She 
barely  escaped  suppuration  at  the  seat  of  operation,  and  was 
unable  to  return  to  school  for  more  than  three  months. 

It  is  well  known,  that  other  measures  are  recommended, 
for  the  treatment  of  these  tumors,  in  the  average  surgical  text- 
book; as,  injection  with  irritating  fluid,  pressure,  etc. 

But,  their  free  injection  may  be  followed  by  a very 
troublesome  inflammation. 

Moderate  pressure  is  not  effectual;  though,  if  we  deal  with 
them  by  the  severe  application  of  concussive  force,  a cure  as  a 
rule,  will  aften  promptly  follow.  Sometimes,  however,  in  con- 
sequence of  the  low  grade  of  inflammation,  which  often  super- 


COCAINIZaTION  in  surgery  of  THE  EXTREMITIES.  115 


venes,  after  they  appear,  their  walls  so  thicken,  that  the  con- 
cussive  force  necessary  to  rupture  them,  must  be  directed  in  a 
certain  manner,  and  with  considerable  energy. 

Therefore,  unless  over  patient  is  under  ether  we  will 
probably  fail;  because  of  the  the  pain  induced;  and  that  occa- 
sioned by  the  manipulation  of  a joint,  already  the  seat  of 
morbid  sensativeness. 

For  considerable  time  past,  all  of  these  cases  coming  into 
my  hands  have  been  radically  dealt  with,  by  the  aid  of  cocaine 
injections.  The  technique  of  operative  intervention  may  be  di- 
vided into  three  stages. 

First. — Thorough  asepsis  of  the  parts  and  needle. 

Second. — Hypodermication  with  puncture  of  the  cyst. 

Third. — Sudden  and  considerable  concussion. 

In  all  cases,  the  area  about  to  be  treated  should  be  com- 
pletely cleansed  and  disinfected;  after  which  those  exposed 
parts  above  and  below,  should  be  enveloped  in  sterilized 
towels  or  gauze.  Now,  we  commence  hypodermication,  after 
we  have  prepared  our  solution  and  needle. 

The  first  step  is,  to  plunge  the  needle-point  directly  into 
the  base  of  the  tumor,  and  to  deposit  from  two  to  five  drops 
of  the  solution.  The  remainder  of  the  charge  is  sprayed 
along  the  needletrack.  Then  another  charge  of  the  solution 
is  sent  in,  at  another  angle,  but  this  time  the  cyst  is  not  pene- 
trated. From  thirty  to  forty-five  drops,  have  always  been 
ample,  in  my  experience. 

Cocainization  complete,  the  fore-arm  should  be  firmly 
seized,  and  using  the  hand  as  a lever,  we  should  first,  by 
gradual,  but  firm  and  steady  motion,  to  forcibly  flex  it  on  the 
wrist.  Now*,  we  reverse  this  motion,  and  hyperextend  it,  on 


116  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

the  dorsum  of  the  fore-arm;  when,  again  full  adduction  and 
abduction  are  made.  The  needle-puncture  made  in  the  first 
injection,  serves  two  important  purposes. 

First,  It  deadens  sensation  in  the  interior  of  the  cyst  over 
its  peripheral  surface;  and, 

Second,  On  pressure,  it  allows  the  contents  to  escape, 
into  an  atmosphere  of  vascular  connective  tissues.  In  different 
cases,  by  the  wrist  movement  here  described,  alone,  I have  been 
able  to  crush  those  cysts,  without  doing  anything  further;  but, 
should  this  manipulation  fail,  as  it  often  will,  in  chronic  cases, 
yet  it  frees  all  deep-seated  attachments,  and  liberates  adhesions 
with  adjacent  tendons,  so  that  the  complete  demolition  of  the 
cyst,  which  has  resisted  moderate  pressure  will  be  all  the  more 
complete  and  radical.  After  hypodermication  and  vigorous 
joint  manipulation,  we  are  prepared  for  the  third  stage;  pro- 
vided, the  bursa  still  remains. 

Our  last  and  final  act,  now  will  be,  to  rupture  or  crush  in 
the  cyst-wall,  by  one  or  more  severe  blows,  directed  imme- 
diately over  the  tumor.  With  a view  of  executing  this  step  of 
the  operation  with  precision,  the  mobile  mass  must  be  pushed 
over  and  fixed  on  an  osseus  surface. 

I have  usually  found  the  head  of  the  radius,  to  admirably 
fulfill  the  purposes  of  an  anvil,  in  these  cases.  Most  any 
metallic  substance,  weighing  from  six  oilnces  to  a pound 
will  answer  for  a mallet.  A small  gauze  bandage  is  passed 
around  over  the  wrist  and  bursa.  Its  rough  surface  prevents 
the  tumor  from  rolling  or  gliding  under  the  skin,  when 
struck.  Now,  we  are  ready  for  percussion.  We  should  take 
accurate  aim  and  strike  with  considerable  force;  of  course  in 
each  case,  according  to  the  special  circumstances* 


COCAINIZA T10N  IN  SURGERY  OF  THE  EXTREMITIES  117 


When  we  strike  directly  over  the  bursa;  which  we  steady 
with  the  fingers  of  our  hand,  it  is  totally  destroyed,  but,  if  we 
miss  our  aim,  or  apply  insufficient  force,  then  we  may  give 
pain,  and  besides,  must  repeat  the  blows. 

The  whole  thing,  occupies  much  less  time,  than  it  requires 
to  describe  it.  The  procedure  is  rapid,  radical  and  simple. 
I have  never  seen  or  heard  of  any  unfortunate  sequelae  follow- 
ing the  procedure,  when  judiciously  employed. 

The  after  treatment  is  practically  nil.  The  patient  is  adr 
vised  to  wear  a bandage,  and  to  exercise  the  limb  as  soon  as 
he  desires. 

Observations. 

Dr.  James  Moran,  of  New  York,  brought  a locomotive 
engineer  to  me  during  last  October  (1893),  who*had  a large 
bursa  on  the  dorsum  of  the  right  wrist,  immediately  over  the 
radio-carpal  articulation.  It  had  given  so  much  pain  latterly, 
as  to  render  the  hand  quite  powerless. 

He  had  come  in  to  make  arrangements  for  an  operation. 
He  urged  me  to  so  treat  the  case,  that  he  might  be  laid  off, 
but  a short  time,  as  it  was  a busy  season  of  the  year,  on  the 
line  which  employed  him. 

Then  and  there  in  a few  moments,  by  the  procedure  here- 
to-fore  detailed,  his  bursa  was  destroyed  with  a rapidity,  com- 
pleteness and  painlessness,  that  amazed  him  and  the  doctor. 
He  went  on  his  engine  as  usual  the  next  day,  with  no  more 
stiffness  in  the  joint,  or  neuralgic  pain  in  the  arm  or  fingers. 

Dr.  Wm.  G.  Gaudineer,  of  New  York,  in  the  same  month 
invited  me  to  his  office,  to  see  another  case  of  a similar  char- 
acter, in  a young  woman.  She  had  suffered  for  a long  time 


118  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

from  the  bursa,  and  in  vain,  tried  every  ordinary  remedy. 
Now,  that  it  was  becoming  rather  worse  than  better,  and  the 
hand  was  quite  powerless,  she  applied  for  surgical  relief. 

This  bursa  had  a very  thick  capsule  and  required  several 
severe  blows  before  it  yielded.  She  went  on  about  her  work 
the  next  day,  and  the  result  has  been  entirely  satisfactory.  One 
advantage  about  this  plan  of  treatment  is,  that  it  permits  of 
our  patient  continuing  at  his  usual  occupation;  which,  to  work- 
ing men  or  women  is  a great  gain. 

Perhaps,  in  the  cold,  frosty  weather  of  winter,  it  would  be 
prudent  to  require,  that  the  parts  be  kept  well  covered,  and 
in  a state  of  rest,  for  two  or  three  days,  before  the  hand  is 
used. 


CHAPTER  XVII. 


LOCAL  ANALGESICS  IN  THE  SURGERY  OF 
THE  THORAX. 

The  anterior  and  lateral  walls  of  the  thoracic  cage,  in  the 
female,  are  very  often  the  seats  of  such  pathological  conditions 
as  require  the  intervention  of  surgery  for  their  relief  or  cure. 
For  intra-thoracic  conditions,  exclusive  of  those  which  are 
dependent  on  diseases  of  the  pleura,  mechanical-therapeutics 
can  not  accomplish  much. 

The  anterior  and  latteral  walls  of  the  thorax  are  more 
intolerant  to  incised  or  punctured  wounds,  than  any  other  part 
of  the  body. 

Many  times,  we  will  observe  the  most  alarming  collapse 
and  shock,  following  penetrating,  surface  wounds  over  the 
thorax.  In  fact  the  constitutional  symptoms  have  been,  alto- 
gether out  of  proportion  with  the  local  conditions. 

The  mammary  and  the  axillary  regions  are  those,  most 
tolerant  to  the  mechanical  division  of  the  tissues. 

Even  now,  though  hand  to  hand  encounters  in  battle,  are 
unusual,  yet,  many  nations  of  Europe  have  their  Cuirrassier’s; 
(those  troops  who  wear  heavy  leather  shields  over  their  chests) 
for,  it  is  well  known  that  the  thorax  is  the  most  vulnerable,  to 
sharp  edged  weapons. 


— 119— 


120  LOCAL  ANAlS  THE  TICS  AND  COCA/ND  ANALGAES1A. 

It  cannot  be  said  that  cocainization  is  a satisfactory  agent 
for  surgical  operations,  on  the  thoracic  appendages. 

My  experience  with  its  employment  over  these  areas  of 
the  body,  have  not  encouraged  me  to  continue  them,  unless 
there  are  circumstances  and  special  conditions,  which  should 
exclude  pulmonary  anaesthetics;  and  even  then,  I would  not 
employ  them,  unless,  the  patient  was  first  carried  to  the  point 
of  inebriation,  before  cocainization  was  undertaken.  It  may  be 
however,  that  with  time,  we  may  devise  such  a technique  as  will 
so  completely  fulfil  the  requirements  of  a local  analgaesic  that 
we  can  quite  generally  discard  the  volatile  anaesthetics  here. 
At  the  present  time,  we  can  not  very  well  recommend  a local- 
analgaesic,  for  opening  an  abscess  of  the  breast;  because  with 
a keen  lance,  and  a dextrous  hand,  one  can  reach  a pus-cavity 
with  as  little  pain,  as  to  insert  a hypodermic-needle.  The 
breast  is  richly  provided  by  a nerve  supply  from  various 
sources,  which  endows  it  with  exquisite  and  special  sensa- 
tiveness. 

It  is  a very  vascular  organ,  which  may  give  us  serious 
trouble  in  operations  on  it,  if  one  is  not  skilled  and  well  pre- 
pared to  deal  with  profuse  haemorrhage.  Large  and  repeated 
hypodermic-injections  must  be  made  to  annul  a large  zone  of 
tissue,  which  the  scalpel  must  deeply  cleave,  in  all  neoplastic 
formations  which  occupy  the  mammary-gland. 

We  may  succeed  in  benumbing  the  cutaneous  filaments, 
but  as  the  deeper  perimammary  and  submammary  tissues  are 
reached,  the  suffering  is  considerable.  This  is  precisely  the 
juncture,  at  which  our  dissection  must  be  somewhat  tedious 
and  critical,  and,  when  too,  a quiescent  state  is  imperative. 

In  those  breast  amputations  which  entail  a long  incision 


C0CAIN1ZA TION  IN  SURGERY  OF  THE  THORAX.  121 


into,  and  opening  up,  of  the  axilla,  cocaine  is  quite  out  of  the 
question. 

Within  the  past  six  months  three  cases  have  come  under 
my  care  for  operation,  which  illustrate,  in  a certain  degree,  the 
unsatisfactory  character  of  cocainization  in  the  surgery  of  the 
mamma  and  thorax. 

Case  One. — Patient,  30  years  old,  single,  female,  in  gen- 
eral good  health.  She  was  suffering  from  an  epithelioma  of 
the  right  mammary  gland.  The  tumor  was  about  the  volume 
of  a medium-sized  orange,  and  was  lodged  towards  the  lower 
and  inner  border  of  the  gland.  The  nipple  was  slightly  re- 
tracted, through  the  mass  was  freely  movable.  As  it  had 
become  the  source  of  constant  pain,  she  was  anxious  to  have 
it  removed,  but,  she  protested  against  taking  ether,  because, 
about  one  year  before,  her  sister  had  been  operated  on  for  a 
similar  tumor  of  the  breast,  and  died  under  ether-anaesthesia, 
she  said,  on  the  table.  We  therefore  decided  to  test  the  value 
of  cocainization  in  this  case. 

The  parts  were  prepared  in  the  usual  manner,  and  one 
hundred  drops  of  a one  per  cent  solution  of  the  alkaloid  were 
inserted,  some  immediately  beneath  the  integument,  some  into 
the  margins  of  the  growth,  and  others  deeply  under  it. 

She  was  a woman  of  great  determination  and  fortitude; 
and,  though  there  was  apparently  no  pain  caused  by  the  divi- 
sion of  the  integument;  but,  as  the  edge  of  the  scalpel  passed 
through  the  connective  tissue,  and  the  tumor  was  rolled  out 
from  its  deep  attachment,  with  the  capsule  of  the  gland  and 
the  pectoral  muscle,  the  suffering  was  very  great. 

She  became  deathly  pale;  the  pulse  was  quick  and 
thready,  and  she  breathed  irregular,  deep  gasps. 


122  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

By  the  time  the  vessels  were  all  secured,  and  the  divided 
surfaces  were  closed  in,  she  recovered  herself.  She  reacted 
promptly  and  made  a rapid  recovery 

Indeed,  the  operation  and  the  result  were  all  that  could 
be  desired,  except,  that  it  seemed  cruel  to  inflict  severe  pain, 
when  it  was  possible  to  wholly  prevent  it.  Nevertheless,  she 
was  perfectly  satisfied,  and  said,  if  she  would  ever  require  a 
similar  operation,  she  would  prefer  to  go  through  the  same 
course,  than  risk  the  dangers  of  ether  or  chloroform. 

Case  Two.— Early  in  September  (1893),  an  elderly  female, 
was  sent  to  me  suffering  from  a large,  chronic,  painless  tumor 
on  the  right  aspect  of  the  chest. 

It  was  rather  inside  and  above  the  nipple,  and  seemed  to 
have  developed  from  the  periphery  of  the  gland,  rather  than 
near  the  nipple.  She  came  to  have  the  mass  removed,  rather 
because  of  its  deforming  effects,  and  because  it  lately  had 
rapidly  increased  in  size,  than,  that  it  gave  her  any  inconveni- 
ence, for  she  never  had  any  pain  in  it. 

She  was  68  years  old,  of  a spare  build,  and  there  was  no 
evidence  of  a cancerous  cachexia.  On  examination  it  was 
clear,  that  she  had  considerable  cardiac  hypertrophy  with  val- 
vular disease. 

She  expressed  a strong  repugnance  to  taking  ether  or 
chloroform,  and  declared  she  was  ready  to  endure  the  pain  of 
operation,  provided  she  could  be  assured  that  she  would  sur- 
vive it. 

Considering  her  chances  from  my  experience  with  the 
preceding  case,  and  believing  from  the  physical  qualities  and 
anatomical  character  of  the  mass,  that  its  removal  would  be 
but  the  work  of  a few  moments,  she  was  informed  that  there 


C O CAINIZA T1  ON  IN  SURGERY  OF  THE  THORAX.  123 


was  every  reasonable  prospect,  that  she  would  come  safely 
through. 

As  she  always  lived  a severely,  abstenious  life,  she  bore 
alcoholics  poorly,  so  that,  when  she  was  placed  on  the  table, 
she  was  wanting  in  that  spirit  and  courage  which  spirituous 
liquids  give. 

On  the  contrary,  she  was  extremely  melancholy  and 
peevish;  besides,  inclined  to  find  fault  with  everything. 

Hypodermication  was  attended  with  great  difficulty. 
With  every  insertion  of  the  needle,  she  loudly  screamed  and 
tried  to  roll  from  one  side  to  another.  It  was  now  realized, 
that  we  had  a very  troublesome  case  to  operate  on. 

Accordingly,  when  it  was  decided  that  cocainization  had 
been  carried  far  enough,  and  the  surface  was  suddenly  chilled, 
two  deep,  long  ovals  were  quickly  made  with  the  scalpel, 
through  the  skin  and  deep  fascia,  when  the  mass  was  seized, 
and  raised  from  its  deep  attachments  with  ease  and  rapidity; 
in  the  meantime,  the  patient  emptying  her  vials  of  wrath  upon 
me  “for  practicing  a deception  on  her.”  The  completion  of 
the  operation  was  simple  and  occupied  but  a few  moments. 
The  old  lady  lost  but  little  blood,  and  had  but  little  shock. 

The  wound  healed  very  rapidly,  and  two  weeks  aTer  op- 
eration, she  left  for  home.  By  this  time  she  had  experienced 
a change  of  heart,  and,  on  leaving  apologized  for  her  conduct 
on  the  day  of  operation. 

Case  Three. — Patient,  a robust  vigorous  man,  36  years 
old.  About  a j ear  before,  while  intoxicated,  he  was  thrown 
from  a wagon,  and  fractured  the  seventh  and  eighth  ribs,  at  a 
point  corresponding  to  the  vertical  nipple-line.  But,  he  con- 
tinued at  his  usual  work,  without  applying  any  description  of 


124  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGaESIA. 

treatment;  but,  his  injured  side  gave  him  more  or  less  pain 
when  he  performed  heavy  labor,  and  for  more  than  a month 
previous  to  entering  the  hospital,  a fistulous  opening  appeared 
at  the  seat  of  fracture,  which  had  discharged  pus  intermit- 
tantly;  besides,  it  was  very  painful  to  the  touch,  or,  on  sudden 
motion  of  the  body. 

His  physician,  discovering  evidence  of  shattered,  necrosed 
bone,  had  recommended  surgical  measures. 

On  examination,  with  the  probe,  dead  bone  was  readily 
detected,  at  the  tip  of  it.  On  the  day  fixed  for  the  operation 
of  resection  of  the  diseased  costal  structures,  he  stubbornly 
refused  to  take  ether,  and  said  he  would  bear  a little  pain, 
rather  than  use  the  “stuff.” 

The  case,  then  was  another,  in  which  to  give  cocaine  a 
fair  trial,  though,  it  may  be  premised  that  he  imbibed  with 
relish  more  than  eight  ounces  of  whiskey,  before  cocainization 
was  Commenced;  and  would  have  taken  much  more  if  we  had 
offered  it.  The  tissues  over  the  seat  of  necrosis  were  boggy, 
with  hard,  indured  margins,  requiring  a long  and  strong  needle 
to  piece  them.  About  one  hundred  drops  were  sprayed 
through  the  muscular  and  connective  tissue,  when,  after 
surface  chilling,  the  incision  was  made. 

This  incision  was  bisected  by  another,  so  that  through  a 
large  conical  gap,  well  retracted,  one  was  enabled  to  reach 
the  costal  periosteum,  which  was  considerably  thickened.  He 
gave  no  expression  to  suffering  until  the  periosteum  was 
penetrated.  This  could  not  have  been  well  cocainized. 

Now  he  commenced  swearing,  and  kept  it  up,  until,  all  the 
disintegrated  bone  was  freely  exposed  and  gouged  out  of  its 
thick  periosteal  bed.  We  observed  great  caution  to  avoid 


C0CA1N1ZA  TION  IN  SURGERY  OF  THE  THORAX.  125 


opening  the  pleural  cavity.  The  diseased  tissues  cleared 
away,  the  wound  was  solidly  closed  from  below,  with  catgut 
suture. 

The  closing  of  the  parts  seemed  to  give  him  little  or  no 
pain.  After  the  operation  was  complete  and  he  was  returned 
to  bed,  he  expressed  himself  as  well  pleased,  and  declared,  that 
if  he  ever  had  a similar  operation  performed  on  him,  he  would 
prefer  cocaine  to  relieve  the  pain. 

In  this  case  it  must  be  confessed,  that  the  performance  of 
the  operation  was  much  more  easy  than  it  would  have  been 
under  ether.  There  was  no  strangling,  choking,  vomiting,  or 
tetanic  spasms,  which  are  so  common  in  the  etherization  of 
large-framed,  vigorous  young  men. 

The  sequelae  were  very  simple.  Union  was  rapid,  aseptic 
and  solid.  He  left  the  hospital  on  the  fifth  day,  though  he 
returned  once,  for  a final  dressing  of  the  wound. 

These  three  cases  constitute  the  sum  total,  of  my  experi- 
ence with  local  cocainization,  in  the  surgery  of  the  external 
appendages  of  the  thorax.  That  it  possesses  valuable  proper- 
ties here,  no  one  who  has  given  it  a fair  trial,  will  dispute. 

For  innocent,  moderate-sized  tumors,  freely  mobile  and 
outside  the  mammary  district,  or  any  part  of  the  thorax,  it 
should  be  preferred  to  pulmonary-anaesthetics;  unless,  there 
are  special  and  urgent  reasons,  for  employing  the  latter. 


CHAPTER  XVIII. 


COCAINIZATION  IN  THE  SURGERY  OF  THE 

ABDOMEN. 


The  abdomen  provides  us  with  the  most  fertile  field  in 
the  body,  for  the  utilization  of  cocaine-analgaesia.  But,  even 
this  great  region,  has  its  limitations,  and,  is  often  the  seat  of 
many  pathological  conditions,  in  which,  it  must  be  discarded. 

If  we  divide  the  abdomen  by  a horizontal-line,  passing 
through  the  umbilicus,  into  two  great  districts,  we  will,  with 
considerable  precision,  locate  those  sub-districts,  wherein 
cocaine  plays  a marvelous  role  as  a local  analgaesic,  and  as  a 
life-saving  agent;  and,  those  in  which  it  cannot  be  relied  on. 

It  is  well  known,  that  all  abdominal  sections  above  the 
umbilical  line,  are  attended  with  a greater  mortality  than  those 
below  it;  that  their  performance  is  followed  by  a greater  diffi- 
culty; and,  generally  occupy  more  time.  It  practically  has  no 
place,  in  the  surgery  of  the  epigastric,  the  right  or  left  hypo- 
chondriac, or  the  umbilical  regions.  In  the  lumbar  regions, 
there  are  conditions  in  which  it  may  be  most  happily  em- 
ployed. In  the  hypogastric,  the  right  and  left  inguinal  re- 
gions, cocainization  occupies  an  unrivaled  position. 

It  is  important,  however,  to  always  remember,  that  when 
employing  this  agent  as  an  analgaesic  in  the  surgery  of  the 
abdomen,  that  we  proceed  on  certain  definite  rules. 


—126— 


C 0 CA  IN IZ  AT  ION  IN  SURGERY  OF  THE  ABDOMEN.  127 


With  the  single  exception  of  hernia,  cocaine  should  not 
be  employed  in  the  surgical  intervention,  of  any  pathological 
lesion,  which  is  free  and  clear  of  the  parietal  peritoneum;  nor 
should  we,  in  any  operation,  in  this  region,  which  may  be  at- 
tended with  a tedious  dissection  or  complicated  manipulation, 
commence,  without  having  a pulmonary-anaesthetic  within 
convenient  reach. 


Enumerations  of  the  Pathological  Conditions  in  Which 

COCAINIZATION  MAY  BE  UTILIZED  WlTH  ADVANTAGE, 

From  Above  Downwards. 

First. — For  Pyo-Nephrosis,  or  Hydro-Nephrosis;  Lumbar 
Cysts  or  Abscess;  Lumbar  Colotomy;  Pericaecal;  Encysted 
Abscess  in  Appendicitis. 

Second. — Cystotomy  for  Vesical  Evacuation,  or  for  Stone 
in  the  Bladder. 

Third. — For  Hernia  in  the  Inguinal  or  Crural  Regions. 

In  those  pathological  lesions,  of  the  renal  structures  at- 
tended with  a large,  encysted,  accumulations  of  pus,  or  a volu- 
minous quantity  of  urine,  caused  by  a blocking  or  stenosis  of 
the  ureter;  and  in  which  but  one  kidney  preserves  its  func- 
tional activity,  cocainization  serves  other,  than  those  primary 
purposes  previously  claimed  for  it.  Its  employment  here,  en- 
tirely obviates  the  great  danger  which  is  always  present,  from 
suppression  of  the  urine,  through  the  action  of  ether  on  the 
sound  kidney.  The  operation  is  entirely  rectro-peritonetal. 
Under  cocaine  we  may  tap  the  abdominal  wall,  or  we  may 


128  LOCAL  AN  AES  THE  TLCS  AND  COCALNE  ANALGAESLA. 

penetrate  into  the  parenchyma  of  an  organ  and  lay  open  an 
abscess. 

If  it  is  thought  well,  after  having  evacuated  the  renal  con- 
tents, to  go  further  and  perform  a nephrectomy,  as  we  may 
have  troublesome  haemorrhage  to  deal  with,  then,  we  should 
resort  to  a moderate  etherization. 

In  lumbar  colotomy,  as  our  patients  are  commonly  greatly 
emaciated,  before  the  complete  blocking  of  the  rectum  occurs, 
the  descending  colon  may  be  reached  with  ease,  through  Petit’s 
triangle,  and  an  artificial  anus  made.  To  my  mind,  this  situa- 
tion, presents  many  advantages,  from  various  considerations, 
over  Madyl’s  operation,  of  inguinal  colotomy. 

At  all  events,  lumbar  colotomy,  we  are  told  by  Reclus 
and  others,  is  comparatively  a simple  and  always  a painless 
operation,  under  cocaine.  In  those  cases  of  long-standing 
faecal  obstruction,  there  is  an  auto-toxaemia  from  resorption. 

Now,  to  add  another  lethal  agent  to  the  circulation,  must 
clearly,  render  our  patient’s  prospects  of  recovery,  from  opera- 
tion, much  worse. 

No  opportunity  has  yet  presented  itself  to  me  to  test  this 
description  of  anaesthesia  on  a case  of  lumbar  colotomy,  ex- 
cept one  about  a year  ago,  when  circumstances  prevented  me 
from  taking  it  in  charge.  A message  was  sent  to  me,  to  visit 
a woman  who,  it  was  said,  was  suffering  from  colic  and  consti- 
pation. When  I reached  the  house,  it  was  appaient  that  she 
had  been  freely  dosed  with  morphine,  for,  she  had  pin-hole 
pupils  and  was  well  narcotized.  She  was  so  stupid  that  I 
could  secure  very  little  of  her  history  from  herself.  On  ex- 
amining the  abdomen,  I found  the  colon  enormously  distended, 
the  abdominal  walls  being  greatly  wasted. 


C0CAIN1ZA  HON  IN  SURGERY  OF  THE  ABDOMEN.  129 


Passing,  my  index  finger  of  the  right  hand,  into  the 
anus,  it  was  discovered,  that  the  rectum  was  solidly  plugged, 
by  a solid  impenetrable  mass  of  cancerous  tissue.  As  I had  to 
leave  the  city,  on  this  day,  for  about  a week,  I recommended 
that  she  be  brought  to  a hospital  in  the  vicinity,  for  immed- 
iate operation. 

This  advice  was  not  taken,  and  she  died,  unrelieved,  the 
following  day. 

In  cases  of  localized,  encysted,  typhillitic  abscess  by  the 
aid  of  cocaine,  we  may  inhibit  sensation,  while  an  appropriate 
incision  is  made  and  ample  drainage  is  secured.  In  these 
cases  the  posterior  surface  of  the  pyogenic  membrane  is  extra- 
peritoneal,  and  easily  reached,  when,  the  seat  of  active  in- 
flammation. 

Such  case  came  under  my  care  in  the  practice  of  Dr. 
Pyne,  of  Yonkers,  N.  J.,  a little  more  than  a year  ago,  The 
patient  was  a young  man  of  20,  a student,  who  had  been 
suddenly  seized,  with  violent  abdominal  pain. 

When  an  abscess  had  been  diagnosed,  I was  sent  for  to 
operate.  Cocaine  was  employed,  in  the  usual  manner;  but  it 
was  found  to  be  a complicated  case,  requiring  a very  tedious 
manipulation,  and  sensation  of  pain  returned  before  the  opera- 
tion was  completed.  He,  however,  made  a very  satisfactory 
recovery. 

In  some  of  these  cases,  which  have  run  a chronic  course, 
the  muco-purulent  mass  spreads  far  backward,  into  the  retro- 
peritoneal tissues,  behind  the  kidney;  or,  as  in  the  case  of  a 
child  which  came  under  my  care,  last  March,  the  pus  may  take 
a forward  direction  over  the  latero-anterior  wall  of  the  abdo- 
men, and  make  its  way  out  at  the  umbilicus. 


130  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAESIA 

With  this  class,  if  there  are  no  special  impediments  in  the 
way,  ether  should  be  employed;  for,  if  our  operative  inter- 
vention here,  is  not  radical  and  thorough  all  is  lost;  or  we 
may  leave  our  patient  in  a very  much  worse  condition,  than  if 
nothing  had  been  undertaken. 


CHAPTER  XIX. 


COCAINIZATION  IN  SUPRA-PUBIC  OPERATIONS 
ON  THE  BLADDER. 


The  bladder  in  the  male  is  so  far  uncovered  anteriorly,  by 
the  peritoneum,  that  it  may  be  reached  through  the  space  of 
Rezius,  and  explored  without  danger  of  infecting  this  serous 
membrane. 

But  Guyon,  of  the  Hospital  Necker,  of  Paris,  has  recently 
demonstrated,  that  there  are  certain  localized  lesions  of  the 
interior  of  the  bladder,  which  may  be  as  safely  and  more 
completely  treated,  by  a laparotomy,  with  an  incision  directly 
through  the  exposed  fundus;  which,  is  closed  later  hermatical- 
ly,  by  two  or  more  rows  of  sutures. 

Those  supra-pubic  operations  on  the  bladder,  are  not 
such  innocent  and  simple  procedure  as  they  seem;  for,  at 
this  site  drainage  is  not  satisfactory,  and  the  danger  of  in- 
fection is  great. 

Their  mortality  is  considerable.  But,  there  are  circum- 
stances which  justify  or  demand  an  entrance  to  the  bladder 
through  this  route.  In  many  of  these,  there  is  chronic 
vesical  trouble,  with  associate  renal  disease.  Here,  it  would 
be  an  incalculable  boon,  if  we  could  obviate  the  disasters 
which  so  frequently  result,  as  a sequence  of  nephritic  de- 


—131— 


132  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

rangements,  consequent  on  ether  administration,  for  vesical 
operations. 

No  case  appropriate  for  a test  of  cocainization,  in  supra- 
pubic operations  has  presented  itself  to  me,  therefore,  I am 
unable  to  speak  of  its  value  in  them,  from  personal  ob- 
servation. However,  as  the  operative  area  in  suprapubic  cases 
is  a narrow  one;  is  not  occupied  by  any  large  blood-trunks  in 
its  centre,  in  such  cases,  as  simple  incision  of  the  bladder-wall 
for  the  evacuation  of  urine  in  neoplastic  obstruction,  with  the 
permanent  fixation  and  drainage  of  the  bladder,  through  the 
route;  for  the  removal  of  large  calculi,  or  other  conditions, 
which  precludes  intervention  by  way  of  the  perineum,  and  in 
all  cases,  in  which  we  are  in  possession  of  unerring  proof,  that 
the  kidneys  are  the  seat  of  extensive  changes,  we  should  not 
hesitate  to  employ  cocaine,  as  an  analgaesic. 


CHAPTER  XX. 


COCAINIZATION  IN  KELOTOMY  FOR  STRAN- 
GULATED HERNIA,  AND  IN  OPERATIONS 
FOR  THE  RADICAL  CURE  OF  THE 
NON- STRANGULATED  VARIETIES 
OF  HERNIA. 

Cocainization  has  radically  revolutionized  the  treatment  of 
strangulated  hernia;  though,  not  to  such  an  extent  yet,  as,  no 
doubt,  it  will  later,  when  its  analgaesic  properties  are  better 
known,  and  the  technique  for  its  administration  is  more  com- 
pletely understood. 

Heretofore,  the  mortality  from  operations  for  strangu- 
lated hernia  has  been  enormous.  It  is  one  of  those  surgical 
lesions,  the  treatment  of  which,  it  appears,  has  been  in  no 
manner  improved  by  antiseptics. 

In  my  student  days,  I was  amazed  at  the  fearful 
mortality  which  followed  these  operations,  even  when  per- 
formed under  the  hands  of  master  operators;  and  what  I saw 
in  my  interneship  later,  in  no  manner  diminished  my  impres- 
sion, of  the  terrible  seriousness  of  these  cases.*  I have  seen 
the  patient  die  on  the  table  before  operation  could  be  com- 
pleted; others  sank  in  mortal  collapse,  or  never  came  from 
under  the  anaesthetic  after  they  were  returned  to  their  beds. 


—133— 


134  LOCAL  ANyES  THE  TICS  AND  COCAINE  ANALGsESIA. 

Finally,  when  engaged  in  an  active,  mixed,  surgical  service,  I 
must  confess,  that  there  was  no  class  of  operations  which  gave 
me  so  much  anxiety,  as  those  cases  for  hernial  strangulation. 

It  certainly  would  be  unfair  to  attach  all  the  blame  to 
the  operation,  for  the  large  lethality;  for,  in  a certain  number, 
the  practitioner  had  irretrievably  damaged  the  bowel  by  an 
excess  of,  or  misdirected  taxis;  or,  by  allowing  too  protracted 
delay.  But,  that  the  operation  itself  did  not  add  enormously 
to  the  dangers,  in  incomplicated  cases,  it  would  be  idle  to 
dispute. 

Taking  a retrospective  view  into  the  past,  and  carefully 
analyzing  all  the  factors  which  led  to  a fatal  termination  in 
these  cases,  it  is  my  firm  conviction  that  it  was  the  ether  or 
chloroform  anaesthesia,  which  was  responsible  for  more  deaths 
than  all  other  causes  combined. 

Practitioners,  knowing  the  small  chance  their  patients 
with  strangulated  hernia  had,  after  operation,  exhausted  every 
expedient,  before  they  finally  committed  him  to  the  operator. 

Therefore,  it  had  come  to  such  a pass  that  cases  were 
often  sent  in,  in  a moribund  state,  or  with  the  bowel  bursted 
or  gangrenous. 

But  now,  things  are  changed,  as  it  is  more  generally 
known  that  an  operation  should  save  every  case;  and,  that  the 
practitioner,  with  or  without  skilled  assistants,  may  always 
himself  overcome,  at  least  the  immediate  dangers;  though, 
perhaps,  not  sufficiently  skilled  to  perform  an  entire  herni- 
otomy secundeni-artem,  we  should  rarely  hear  of  a death,  from 
an  operation  for  strangulation.  Few  who  are  not  practically 
familiar  with  operations  for  strangulation,  perhaps,  would  re- 
gard with  skepticism  the  mortality  figures;  or,  believe  that 


C0CA1NIZA TION  IN  SURGERY  OF  HERNIA. 


135 


heretofore,  the  patients’  chances  of  recovery,  were  but  little 
greater  than  death. 

Let  us  see,  what  our  British  cousins  have  to  say  on  this 
point. 

Mr.  Anthony  A.  Bolby  {London  Lancet , May  20,  1893, 
“Mortality  after  Operations  for  Strangulated  Hernia’’),  states 
that  the  mortality  at  St.  Bartholomew’s  Hospital  for  the  past 
ten  years  (from  1883  to  1893)  was  40  per  cent. 

He  further  added,  “that  the  mortality,  for  operations  for 
strangulated  hernia,  was  much  higher  than  was  generally  sup- 
posed.” He  quoted  from  Barry’s  figures  of  1884,  to  show  that 
in  940  cases,  treated  consecutively  in  Guy’s,  St.  Thomas’, 
and  St.  Bartholomew’s  Hospitals,  the  death  rate  was  43  per 
cent:,  being  about  the  same  in  each  institution. 

Mr.  F.  Treves,  in  discussion  on  Mr.  Lockwood’s  paper, 
April  4,  1891,  said,  “that  the  average  mortality  in  all  the  Lon- 
don Hospitals,  for  operation  in  strangulation  cases,  was  about 
50  per  cent.” 

Mr.  Bolby  summarizes  as  follows:  for  165  operations  for 
femoral  hernia,  strangulated,  59  deaths, =37. 7 mortality.  In- 
guinal hernia,  104  operations,  30  deaths;  or  28.8.  Umbilical 
hernia,  24  cases,  with  14  deaths,  or  50  percent.  A total,  in 
his  own  practice,  of  293  cases,  with  103  deaths;  or  35.8  in  St. 
Bartholomew’s  Hospital,  for  the  past  ten  years. 

He  added,  “that  the  mortality  need  not  be  more  than  5 
or  ten  per  cent.,  as  few  die  from  the  operation;  the  majority 
being  fatally  injured,  before  operation.  Peritonitis  causes  but 
a small  minority  of  deaths.  When  it  does  occur,  it  is  usually 
from  perforation.  He  had  known  perforation  to  occur  nine 
days  after  operation.  Most  deaths  are  due  to  starvation,  ex- 


136  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGALSIA. 

haustion,  retching  and  pain.”  The  former  quotation  has  been 
made  nearly  completely  from  the  original,  because,  it  so  fully 
and  scientifically  summarizes  many  of  the  most  salient  features, 
observed  in  strangulation  cases. 

He  truly  says,  “that  the  operation  is  often  unjustly 
blamed;  and  the  major  portion  come  under  the  surgeon’s 
knife,  only  when  pain,  retching  and  exhaustion  have  done 
their  deadly  work.” 

Yet,  withal,  there  has  been  a larger  margin  of  fatal  cases, 
dependent  on  the  shock  of  operation,  than  Mr.  Bolby  is  willing 
to  acknowledge. 

Certainly,  we  cannot  scarcely  attribute  death  to  retching 
or  pain,  when  there  has  been  little;  and,  when  our  patient 
possesses  a goodly  share  of  vitality,  before  operation. 

But,  an  operation  for  strangulation,  should  not  of  itself 
entail  such  grave  dangers.  There  is  practically  no  blood  lost; 
no  vital  parts  are  manipulated;  and  in  skilled  hands  is  a simple 
and  rapid  procedure. 

Wherein,  then,  lies  the  secret  of  this  dreadful  mortality, 
in  recent  uncomplicated  cases? 

My  answer  is,  that  it  lies  in  the  pulmonary  anaesthetics. 
Unhappily,  in  any  surgical  operation,  in  which  pulmonary 
anaesthetics  are  employed,  our  patient  has  to  face  a double 
danger,  and  in  strangulated  hernial-cases,  this  is  particularly 
the  case,  as  an  abundant  experience  has  many  times  con- 
vinced me. 

Now,  precisely  why  this  should  apply,  rather  to  strangu- 
lated hernial  operations  than  to  others,  I am  unable  to  say,  or 
to  explain,  except  on  the  hypothesis  of  what  is  known,  as 
“ether  shock;”  or  that  state  of  collapse,  so  commonly  ob- 


C0CA1NIZATI0N  IN  SURGERY  OF  HERNIA. 


137 


served,  after  an  anaesthetic  has  been  carried  to  full  coma; 
when  the  reaction  and  collapse,  which  succeed  to  over  stimula- 
tion are  so  great,  as  to  completely  overwhelm  an  already  over- 
strained and  weakened  system. 

Pain  is  a cardiac  depressant  of  great  potency  and  when 
intensely  poignant  and  long  continued,  induces  deep  collapse. 
Now,  it  is  well  known,  that  all  pulmonary-anaesthetics,  first 
stimulate  and  consecutively  depress.  Hence,  it  may  be  in 
many  cases  of  operation  for  strangulation,  ending  mortally, 
that  the  accumulative  depression,  following  the  primary  pain 
and  the  volatile  chemical,  was  too  great  for  the  recuperative 
powers  of  Nature  to  overcome. 

In  my  own  early  experience  in  operations  for  strangula- 
tion, by  the  method  then  in  vogue,  the  mortality  was  some- 
thing appalling. 

With  such  untoward  results,  after  the  use  of  the  scalpel, 
very  naturally  tentative  methods,  taxis,  posture,  cold  appli- 
cations, etc.,  were  strained  to  their  utmost,  before  resort  was 
had  to  surgical  intervention. 

Now,  however,  the  whole  aspect  of  affairs  is  changed,  and 
in  every  case  of  strangulation,  attended  with  serious  symptoms, 
after  moderate  taxis  has  been  once  fairly  tried  and  fails;  then, 
an  operation  should  be  immediately  performed,  under  cocaini- 
zation. 

Under  cocaine  analgaesia,  in  all  uncomplicated  cases  of 
strangulated-hernial  operations,  the  mortality  has  fallen  from 
more  than  fifty  per  cent,  to  practically  nothing.  Certainly, 
when  a man  has  been  tampered  with,  until  grave  symptoms  set 
in,  and  he  is  then  hurried  out  of  a warm  room  into  a cold  am- 
bulance, and  transported  over  the  rough  pavements,  for  one  or 


138  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

more  miles,  to  a hospital,  we  need  not  expect  impossibilities, 
from  any  sort  of  surgical  therapy. 

The  operations  for  strangulated  hernia  may  be  divided 
into  two  general  classes. 

First. — Those  that  embrace  the  relief  of  the  strangulation, 
and  that  alone — incomplete  operation. 

Second. — Those  in  which  is  added  to  the  former,  the 
additional  procedures  for  a radical  cure — complete  operation. 

The  hypodermication  of  cocaine,  supplies  us  with  an  anal- 
gsesic  action  of  sufficient  potency  and  duration,  to  painessly  deal 
with  either.  There  is  no  operation  in  surgery,  in  which  the 
great  advantages  of  a local  anaesthetic  are  more  evident,  than 
in  this  class. 

At  a time,  after  intestinal  replacement,  when  the  most 
absolute  quiescence  is  necessary,  we  will  have  with  cocaine, 
none  of  that  retching  or  vomiting,  so  common  after  general 
anaesthetics. 

We  have  no  more  post-operative  shock,  because  a kelot- 
omy  entails,  but  a superficial  division  of  the  tissues,  and  no 
great  blood  or  nerve  trunks  are  severed,  besides  when  decor- 
tication of  the  sac,  or  its  contents  is  proceeded  with  properly, 
the  elements  of  the  cord  entirely  escape  injury.  Our  patient 
takes  any  position  which  we  may  direct,  so  that  on  the  whole 
this  formerly  formidable  operation,  is  at  once  stripped  of  many 
of  its  former  dangers  and  greatly  simplified. 

Therefore,  with  cocainization  within  reach;  at  the  present 
time  there  is  no  excuse  or  justification,  for  protracted  delays 
in  strangulated  hernial  cases,  attended  with  dangerous  symp- 
toms; but  immediate  operation  must  be  done  early,  and  the 
imprisoned  bowel  released.  If  the  medical-attendant  be  not 


C0CAIN1ZA  TION  IN  SURGERY  OF  HERNIA. 


139 


an  experienced  operator,  he  should  perform  the  incomplete 
operation,  and  allow  his  patient  ample  time,  for  full  recupera- 
tion, before  he  will  turn  him  over  to  the  surgeon,  for  definite 
treatment. 

By  the  incomplete  operation  is  understood,  that  procedure, 
in  which,  our  objective  point  is  the  immediate  release  of  the 
obstruction,  in  the  intestinal  current.  Therefore,  its  details  are 
but  few,  and  of  a rudimentary  order. 

Our  operative  area  will  be  of  diminished  proportions,  and 
the  time  occupied  will  be  very  short.  Remembering,  that  our 
only  and  cardinal  purpose  in  view,  is  to  relieve  the  intestinal 
stenosis,  we  will,  according  to  the  type  of  hernia  before  us, 
reduce  the  intestine  or  not.  In  a case,  in  which  the  intestine 
has  suddenly  and  recently  slipped  out,  through  the  internal  or 
external  ring,  our  purpose  will  be  best  achieved,  by  simply 
cutting  down,  freely  widening  the  canal,  and  returning  the 
bowel.  We  may  open  the  sac  or  not,  according  to  circum- 
stances. In  old  incarcerated  cases,  after  a free  division  of  the 
constricting  canal  or  ring,  opening  of  the  sac  and  complete 
liberation,  at  the  point  of  stenosis,  nothing  more  is  done.  The 
omentum  or  intestine  may  be  left  in  situ. 

It  may  be  said  here,  that  the  reduction  of  the  intestine  is 
not  an  indispensible  part,  of  every  operation  for  strangulation. 
And  further,  let  no  one  search  for  a constriction  of  the  bowel’s 
wall  due  to  a contraction,  in  all  cases,  either  in  the  neck  of  the 
sac  or  in  the  ring;  for,  in  many  there  is  none. 

The  fundamental  condition  in  most  cases,  is  simply  a 
want  of  proportion.  A knuckle  of  intestine  is  crowded  through 
the  ring,  into  a foreign  district,  which  resists  its  intrusion. 
Active  congestion  and  inflammation  follow,  so  that,  in  a short 


140  LOCAL  ANAiS  THE  TICS  AND  COCA/ND  ANALGESIA. 

time,  what  was  forcibly  crowded  out  of  the  abdomen,  has  in- 
creased so  in  volume,  that  it  cannot  get  back.  Now,  the  canal 
of  emergence  has  not  diminished  its  diameters.  The  primary 
indications  in  treatment,  then,  are,  to  so  widen  the  breach,  as 
either  to  remove  pressure,  or  to  permit  the  intestine,  to  return. 

This,  the  so-called  incomplete  operation  secures.  In  fact, 
it  is  essentially  the  old  operation,  except,  that  in  all  cases,  the 
intestine  is  not  returned. 

The  complete  operation  includes  the  radical  cure.  In 
the  larger  number  of  cases,  this  may  be  superadded  to  the 
former,  when  our  patient’s  condition  will  permit  it;  when,  asep- 
tic conditions  may  be  rigidly  observed,  and  we  are  fully  pre- 
pared, to  go  through  with  it. 

It  is  unnecessary  to  detail  herewith,  the  great  diversity  of 
technique,  which  has  been  elaborated  in  the  recent  past;  as  I 
have  endeavored  elsewhere,  to  describe  systematically,  and,  in 
detail,  all  the  more  popular  operations  employed  for  radical 
cure.  (“Hernia,  Its  Radical  and  Tentative  Treatment,  in  In- 
fants, Children  and  Adults.”) 

My  first  case  of  strangulated  hernia,  in  which  cocainiza- 
tion  was  resorted  to,  came  under  my  care,  in  the  summer  of 
1891.  Since  that  time,  I have  operated  on  thirteen  strangu- 
lated cases,  with  the  aid  of  this  analgaesic,  locally  employed. 

Case  One. — Patient,  a female,  24  years  old,  single,  was 
admitted  into  the  Harlem  Hospital,  late  in  the  night  of  the 
25th  of  June,  1891. 

She  had  been  actively  treated  outside,  for  internal  obstruc- 
tion of  the  intestine,  and  I was  sent  for  at  two  o’clock  in  the 
morning — shortly  after  her  admission — to  perform  a lapa- 
rotomy. 


C0CAIN1ZAT10N  IN  SURGERY  OF  HERR/A. 


141 


She  was  now  in  most  profound  collapse,  having  incessant 
faecal  vomiting,  great  thirst,  and  the  well-known,  anxious 
visage  of  one,  sinking  from  intestinal  obstruction. 

Her  extremities  were  cold,  and  the  pulse  barely  percepti- 
ble. I first  inquired  if  she  ever  had  a hernia.  She  denied 
that  she  ever  wore  a truss,  or  had  a rupture. 

But,  on  examination  over  the  crural  region,  a fulness  of 
considerable  size  was  felt,  which,  on  moderate  pressure,  was 
found  very  sensative.  This  she  said  she  had  since  childhood; 
though  now,  it  was  more  painful  than  ever  before.  It  was 
clearly  apparent  to  me,  that  she  had  a strangulated  femoral 
hernia,  and  I was  determined  to  ascertain,  in  this  untoward 
case  what  could  be  accomplished  with  cocaine,  for  with  ether 
anaesthesia,  it  was  clear  she  would  never  react. 

Cocainization  was  employed  in  the  usual  manner.  The 
hernia  proved  to  be  an  epiplocele  with  a small  knuckle  of  in- 
testine, which  had  become  tightly  constricted  just  outside  the 
fulciforne  process  of  the  femoral  canal.  The  dissection  was 
tedious  and  difficult;  but  she  at  no  time,  complained  of  pain. 
After  the  operation,  by  the  aid  of  stimulants  and  artificial 
heat,  she  promptly  reacted.  Her  recovery  was  rapid  and  un- 
eventful. 

Case  Two. — October  12,  1891.  The  patient  was  a female, 
61  years  old,  who  was  suffering  from  strangulation  for  nearly 
two  days,  when  I saw  her.  Everything  had  been  done  to  try 
and  reduce  the  hernia,  but  without  avail.  When  grave  symp- 
toms set  in,  and  she  had  become  very  weak,  she  consented  to 
an  operation,  and  I was  called  in.  On  examination,  it  was 
found,  that  she  had  an  irreducible  femoral  hernia,  which  was 
of  small  volume,  lodged  in  the  left  side. 


142  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

With  the  aid  of  the  attending  physician,  the  parts  were 
prepared  and  cocainized,  and  an  operation  was  performed. 
As  this  had  been  a recent  extrusion,  and  there  were  no  com- 
plications, the  operative  steps  were  simple  and  rapidly  carried 
out. 

With  this,  as  in  the  preceding  case,  a radical  cure  was 
superadded  to  the  manipulation,  for  relief  of  strangulation. 
After  the  operation  the  vomiting  ceased,  and  she  expressed 
herself  as  greatly  relieved. 

Everything  went  on  well  until  the  third  day,  when  the 
abdomen^suddenly  became  tympanitic,  and  the  temperature 
went  up.  She  died  on  the  evening  of  this  date. 

A post-mortem  examination  was  denied.  There  was  no 
theory  which  would  account,  for  the  sudden  fulminant  type  of 
peritonitis,  which  supervened  and  cut  off  life,  except,  that  per- 
foration of  the  intestine  had  occurred  after  reduction. 

Case  Three. — December  n,  1892.  Male  patient,  29 
years  old,  had  inguinal  hernia  on  the  right  side,  for  several 
years;  for  which,  until  the  past  six  months,  he  had  worn  a 
truss.  He  entered  the  hospital  at  nine  o’clock  in  the  evening- 
just  before  noon,  on  this  way,  while  at  stool,  he  unavoidably 
forced  the  rupture  down.  He  first  tried  to  reduce  it,  but 
failed,  and  called  in  a practitioner,  who  after  many  vain  efforts  at 
taxis,  gave  it  up,  and  sent  him  to  the  hospital  in  an  ambulance.. 

On  examination,  it  was  found  that  he  was  suffering  from 
a complete  inguinal  hernia,  on  the  right  side. 

Although,  in  this  case  the  period  of  strangulation  was 
short,  yet  the  constitutional  symptoms  were  well  marked. 

With  the  coil  of  intestine  which  had  escaped,  there  was 


COCAINIZATION  IN  SURGERY  OF  HERNIA. 


143 


a large  mass  of  omentum.  This  was  well  drawn  down,  ligated 
high  up,  on  a level  with  the  internal  ring,  and  cut  away.  Op- 
eration for  radical  cure  superadded. 

Our  local  analgaesic  acted  perfectly.  In  all  those  cases, 
in  which  we  employ  cocaine,  locally  in  strangulation,  when 
the  constriction  is  released,  the  patient  is  at  once  conscious  of 
a great  sense  of  relief.  In  this  instance,  our  patient  made  an 
uneventful,  and  complete  recovery. 

Case  Four. — Patient,  52  years  old,  had  an  inguinal  hernia 
on  the  left  side,  for  years,  and  always  wore  a truss.  I was 
called  to  see  him,  in  the  evening  of  December  20,  1892.  In 
the  morning  while  making  a heavy  lift,  his  hernia  suddenly 
slipped  down  in  a large  volume,  and  he  was  unable  to  replace 
it.  Towards  noon  the  family  physician  was  called.  He  em- 
ployed all  the  usual  expedients  to  reduce  the  mass,  but,  with- 
out success. 

When  I saw  him  his  general  condition  was  not  bad;  but, 
he  loudly  complained  of  the  pain  that  he  suffered  from,  in  the 
left  groin,  where  the  mass  had  escaped. 

The  hernial  mass  was  very  large,  quite  obliterating  the 
penis,  and  causing  a severe  dragging  sensation,  when  he  at- 
tempted to  raise.  When  the  intestine  went  back  he  experi- 
enced so  much  relief,  that  he  declared  he  felt  as  well  ashe  ever 
did.  Radical  cure  superadded. 

He  lived  in  a long  “flat.”  The  operation  was  performed 
on  the  kitchen  table.  His  room  was  situated  at  the  other  ex- 
treme end  of  the  house.  After  the  operation,  when  the  dress- 
ings were  adjusted,  he  got  aff  the  table,  unaided,  and  walked 
to  his  bedroom.  His  recovery,  too,  was  uneventful. 


144  LOCAL  ANALS 1 HE  T1 CS  AND  COCAINE  ANALGESIA. 

Case  Five. — Patient,  male,  driver  of  a brewery- wagon, 
aged  23  years,  was  admitted  to  my  service  at  Harlam  Hospi- 
tal, April  II,  1892.  He  never  had  a rupture  to  his  knowledge, 
until  the  day  before  he  entered  the  hospital. 

On  that  morning,  in  making  a lift,  a fullness  came  down, 
in  his  right  side,  and  gave  him  such  pain,  as  to  nearly  cause 
him  to  faint.  He  was  brought  home,  and  medical-aid  sum- 
moned. At  first  gentle  taxis  was  made,  which  was  followed 
by  etherization,  when  greater  force  was  employed. 

After  many  attempts  had  been  made,  to  reduce  the  rup- 
ture, which  was  on  the  right  side,  and  he  had  been  kept  at 
home  twenty-four  hours,  he  was  sent  to  the  hospital. 

Pie  was  seen  by  me  two  hours  after  admission,  when,  his 
condition  was  extremely  serious.  The  integument  over  the 
right  inguinal  region  was  greatly  discolored,  from  the  violent 
pressure  which  had  been  employed,  and  the  entire  scrotum 
was  greatly  tumified.  His  general  symptoms  were  very  grave. 

The  abdomen  was  greatly  distended,  and  everywhere  sen- 
sative.  He  was  incessantly  vomiting  and  exceedingly  weak. 
Indeed,  he  was  in  great  shock.  Now,  over  the  inguinal  re- 
gion, although  there  was  great  tumification,  of  the  parts  along 
the  planes,  which  should  be  occupied  by  hernial  sac;  yet,  the 
usual  tangible  qualities  of  a hernia  were  wanting  or  masked. 

He  was  now  so  extremely  weak,  that  I hesitated  to  touch 
the  case,  at  all,  as  the  poor  fellow  was  close  on  the  moribund 
state;  but,  as  intervention  offered  the  only  hope,  the  parts 
were  cocainized,  and  the  sac  opened.  Now  the  mystery  was 
cleared  up.  The  sac  was  stuffed  full  of  the  intestinal  contents. 
The  bowel  had  been  ruptured  by  violent  taxis,  and  then 
pressed  up,  to  empty,  into  the  peritoneal  cavity.  As  our  pa- 


COCAINIZA  T10N  IN  SURGERY  OF  THE  BLADDER.  145 


tient  was  now  rapidly  sinking,  the  wound  was  hurriedly  closed. 
One  hour  later  he  succumbed. 

A post-mortem  examination  was  refused. 

Case  Six. — Patient,  a letter  carrier,  25  years  old,  was  seen 
by  me  November  14. 

Two  days  previously,  I was  sent  for  to  operate  on  him  for 
a strangulated  inguinal  hernia  on  the  left  side. 

At  this  time,  when  first  called,  the  rupture  had  been  down 
for  six  hours. 

Not  being  at  home,  the  doctor,  with  an  assistant,  per- 
formed the  operation,  to  release  the  strangulated  intestine. 
After  the  operation  the  symptoms  of  strangulation  continued, 
unabated. 

Hence,  why  I was  again  called.  The  doctor  explained 
to  me  that  the  patient  was  in  a desperate  condition;  whether 
from  perforation,  internal  obstruction,  or  general  septic  peri- 
tonitis, he  was  unable  to  say. 

On  enquiring  as  to  whether  he  was  in  a condition  to  sus- 
tain an  exploratory  laparotomy,  the  doctor  assured  me  he  was 
not;  and  was  rapidly  losing  ground. 

From  this  I gathered  that  the  case  was  quite  hopeless. 
But  I called  on  him.  It  seemed  indeed,  that  the  end  was  not 
far  off.  Vomiting,  unquenchable  thirst,  and  constant  agoniz- 
ing pain,  had  nearly  exhausted  him. 

He  begged  pitiously,  of  me,  to  try  and  save  his  life.  On 
examining  the  abdomen,  it  was  found  extremely  tympanitic 
over  all  its  area.  His  vomiting  was  faecal  and  almost  constant. 

Now  on  inquiring  what  was  the  state  of  the  wound,  I was 
informed  that  it  had  united  by  primary  union.  But  on  remov- 


146  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

ing  the  dressings  a large  fullness  was  found,  just  outside  the 
internal  ring.  It  was  determined  then,  to  re-open  the  wound 
and  examine  the  mass.  With  this  object  in  view,  the  parts 
were  freely  cocainized. 

On  dividing  the  edges  of  the  wound,  and  tracing  up  the 
spermatic-cover,  I soon  came  on  the  unopened  sac,  with  its 
contents,  which  were  yet  locked  outside  the  internal-ring;  the 
constriction  was  divided,  the  imprisoned  intestine  liberated 
and  returned,  the  sac  excised  and  a radical-cure  superadded. 
The  relief  was  immediate  and  permanent.  Within  two  hours 
he  had  a large  evacuation.  His  ultimate  recovery  was  entire, 
and  he  now  carries  the  mail  as  well  a man  as  he  ever  was. 

Case  Seven. — Patient,  a bar-tender,  aged  28  years,  was 
admitted  into  Harlem  Hospital,  August  12,  1893.  This  man 
gave  a history  of  having  had  a fulness  in  his  left  groin,  for 
several  years.  He  said  it  would  alternately,  suddenly  increase, 
and  as  rapidly  diminish  in  size.  One  month  before  he  was 
entered  at  Harlem  Hospital,  he  had  contracted. 

Five  days  before  he  came  to  the  hospital  he  noticed,  that 
the  fullness  in  the  groin  had  suddenly  swelled  in  volume. 
After  this  he  had  colicy  pain,  with  more  or  less  nausea.  He 
called  the  physician’s  attention  to  this,  who  said  that  it  had 
developed  in  consequence  of  the  discharge  from  the  urethra, 
and  advised  repeated  hot  poultices  to  be  applied  over  it.  But 
from  day  to  day  he  became  much  worse,  and  finally  came  to 
the  hospital,  as  his  brother  said,  who  came  with  him,  “suffer- 
ing from  the  bad  disorder." 

On  admission,  he  was  of  an  ashy  white,  and  was  clearly  suf- 
fering from  septicaemia.  It  was  supposed,  that  the  abscess  in 


C0CAIN1ZA  TION  IN  SURGERY  OF  THE  BLADDER.  ]47 


the  groin  had  broken,  under  the  cuticle,  and  that  its  septic 
contents  had  made  their  way  into  the  general  circulation. 

To  me  he  gave  a clear  history  of  strangulated  hernia.  Its 
salient  features  were,  the  sudden  increase  in  size  of  the  bubo- 
nocele in  the  left  groin,  persistent  constipation,  vomiting  and 
colicy  pains,  with  now,  well-marked  peritonitis. 

This  was  my  diagnosis,  after  a very  careful  investigation  of 
the  case.  And  hence,  directions  were  given  to  immediately 
prepare  for  a herniotomy,  using  cocaine  hypodermically,  for 
anaesthesia.  At  this  time,  his  pulse  was  140,  temperature  104.6, 
and  great  sinking  of  the  vital  powers  was  evident.  He  was 
duly  prepared,  when,  a long  free  incision  was  made  over  the 
greatest  convexity  of  the  mass,  from  the  internal,  ring  to  nearly 
the  base  of  the  scrotum. 

As  the  scalpel  penetrated  the  intercolumnar  fascia, 
before  the  wall  of  the  sac  was  reached,  a foul,  faecal,  ichorous 
fluid  issued  up  through  the  incision.  The  sac  was  found 
rotten,  and  the  confined  intestine  ruptured  and  extensively 
gangrenous.  Now,  all  we  could  do  was  to  leave  an  artificial 
anus,  with  the  hope,  that  should  our  patient  survive  the 
profound  toxaemia,  from  which  he  was  suffering,  in  time,  the 
breach  in  the  bowel  might  be  closed,  and  he  would  recover. 

But  faecal  resorption  and  protracted  suffering  had  so 
crippled  the  vital  powers,  that  there  was  no  reaction.  Our 
patient  sank,  early  in  the  morning  following  operation.  A 
post  mortem  was  not  permitted. 

Case  Eight. — April  14,  1893.  Patient,  male  27  years, 
strangulated,  incarcerated,  inguinal  hernia  on  the  right  side. 

Patient  had  suffered  from  hernia  since  boyhood,  and  had 


148  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

worn  a truss  until  one  month  ago.  He  had  been  drinking 
hard,  and  during  the  afternoon,  while  violently  pushing 
another  man,  he  felt  something  give  away  in  the  right  side. 
Immediately  after,  he  became  very  weak  and  began  to  vomit, 
and  suffer  from  very  severe  abdominal  pains.  At  this  juncture 
medical  aid  was  summoned,  when  persistant  attempts  at  taxis 
were  made.  Finally  another  physician  was  called  to  assist, 
when  ether  was  given,  but  all  to  no  avail,  the  rupture  could  not 
be  reduced.  At  about  7 o’clock  at  night,  an  ambulance  was 
called,  and  he  was  conveyed  to  Harlem  Hospital. 

When  I saw  him,  two  hours  after  admission,  he  was 
suffering  greatly  from  shock.  The  extremities  were  cold,  and 
the  pulse  scarcely  perceptible.  He  was  at  once  prepared  for 
an  operation  under  cocaine. 

In  this  case  the  dissection  proved  very  tedious,  for,  we 
found  the  sac  had  come  down,  not,  as  is  most  common,  on 
one  side  of  the  spermatic  cord,  but  directly  through  the 
center  0/  its  anatomical  elements. 

So  that  on  one  side,  we  came  on  to  the  veins  which  were 
very  varicose,  on  the  other  side,  the  artery;  underneath,  lay 
the  vas-deferens,  and  immediately  anterior  was  the  spermatic- 
nerve. 

Notwithstanding,  the  extra  time  consumed  in  opening  and 
decorticating  the  sac,  our  patient  at  no  time  complained  of 
pain.  Radical  cure  was  superadded. 

Patient  made  an  excellent  recovery. 


Case  Nine. — Patient  56  years  old,  captain  in  the  Fire 
Department,  admitted  to  Harlem  Hospital,  August  5.  Had 


C0CA1NIZA  TION  ID  SURGERY  OF  THE  BLADDER.  14!> 


had  hernia  in  the  inguinal  region,  for  many  years,  and  worn  a 
truss  from  time  to  time  but  not  constantly. 

At  about  noon  on  the  day  of  admission,  his  rupture 
suddenly  came  down,  in  large  volume.  Two  physicians  came 
to  his  attendance,  but  after  spending  more  than  two  hours,  in 
forcible  taxis,  without  and  with  ether,  they  gave  up  the  case 
and  turned  it  over  to  the  hospital. 

He  was  admitted  late  in  the  night;  but,  as  the  symptoms  of 
strangulation  were  not  urgent,  he  was  not  operated  on,  until 
the  next  afternoon.  In  this  instance  the  extruded  mass  was 
very  large;  consisting  mainly  of  omental  tissue,  which,  had  in 
places  become  very  adherent  to  the  protruded  intestine. 
These  adhesions  were  each,  carefully  detached,  the  con- 
stricted bowel  was  returned,  when  the  omental  mass  was 
amputated  high  up,  the  stump  being  fixed  in  the  ring. 

The  sac  bisected  into  four  loops,  these  being  secured  in 
two  separate  knots,  the  stump  being  now  completely  enclosed, 
by  the  homologous  application  of  the  peritoneal  investment, 
was  solidly  closed  in  over,  by  the  cellular  membrane  and  in- 
teguments. 

Our  analgaesic  was  entirely  satisfactory,  though  the  opera- 
tion occupied' more  than  three  quarters  of  an  hour,  in  its  per- 
formance. 

Recovery  was  rapid,  the  wound  closing  in  by  primary 
union,  and  he  left  the  hospital  on  the  thirteenth  day.  Radical 
cure  superadded. 

Case  Ten. — Patient,  a female,  57  years  old,  was  admitted 
to  hospital  September  28,  1893,  strangulated  femoral  hernia 
in  left  side.  Hernia  strangulated  for  six  hours.  In  intense 


150  LOCAL  ANAlS  THE  TICS  AND  COCALNE  ANALGJESIA. 

shock.  Persistant  vomiting,  extreme  thirst,  with  the  hyppo- 
cratic  expressions,  so  expressive  of  peritonitis. 

As  strangulated  hernia  is  altogether  a much  more  serious 
accident  in  the  female,  than  in  the  male,  and  quickly  mortal,  if 
not  relieved  early;  as  soon  as  possible,  everything  was  placed 
in  readiness,  no  time  being  lost  in  making  preparation,  for 
operating.  In  a little  more  than  an  hour  after  admission,  the 
construction  was  divided,  under  cocaine-anaesthesia. 

The  protrusion  consisted  of  a coil  of  intestine,  only.  The 
walls  of  the  intestine  were  so  congested  and  tumified  that,  it 
at  first,  seemed  doubtful,  whether  they  preserved  their  vitality, 
and  ultimate  perforation  might  not  succeed  their  return.  The 
operation  occupied  just  25  minutes,  from  the  time  cocainiza- 
tion  was  complete,  and  the  canal  was  sealed.  The  radical 
cure  was  superadded  by  the  same  procedure,  of  homologous 
utilization  of  the  sac,  for  obturation,  as,  in  the  preceding  case. 

Our  patient’s,  general  condition  was  much  better  after  the 
operation  was  ended,  than  before  it  was  commenced.  But,  as 
the  knots  of  the  sac  sloughed,  at  the  external  ring,  convales- 
cence was  retarded,  though  the  parts  ultimately  cicatrized, 
and  she  left  the  hospital,  the  parts  solidly  healed,  four  weeks 
after  entrance. 

Case  Eleven. — Patient,  a waiter,  26  years  old,  was  sud- 
denly seized  with  a strangulated  inguinal  hernia,  on  the  left 
side,  on  the  afternoon  of  September  11,  1893. 

The  patient  had  worked  all  night  previously,  and  went  to 
bed  early  in  the  morning.  He  awoke  and  dressed  at  about 
four  in  the  afternoon,  when  he  went  to  stool.  Here,  while 
straining,  he  felt  his  hernia  come  down  in  large  volume.  In 


C O CA IN1ZA  T ION  IN  SURGERY  OF  THE  BLADDER.  151 

vain,  he  tried  to  return  it.  Then  a practitioner  was  called  in, 
who  spent  nearly  two  hours  endeavoring  to  reduce  it  by  taxis, 
baths,  ether  injections,  etc. 

Failing,  he  recommended  that  an  ambulance  be  called, 
and  the  patient  sent  to  a hospital.  I was  now  sent  for,  reach- 
ing the  house  at  1 1 p.  m.  I advised  immediate  operation;  as 
I saw  by  the  discolored,  tumified  state  of  the  integument,  that 
quite  enough  taxis  had  been  employed.  I sent  out  for  one 
assistant.  An  operating  table  was  extemporized,  and  opera- 
tion was  performed,  in  the  usual  manner,  by  the  aid  of  cocaine 
alone;  never  did  it  work  more  perfectly  in  my  hands.  Our 
patient  had  an  indirect,  incomplete  left  inguinal  hernia.  On 
dissection,  we  found  the  extended  intestine  intensely  con- 
gested, with  the  sac  widely  distended  by  a blood  clot  and 
serum. 

Immediate  relief  was  experienced,  on  release  of  the 
bowel.  Radical  cure  was  superadded  by  the  same  method  of 
homologous  obturation,  as  in  preceding  cases. 

The  parts  united  by  first  intention,  and  in  three  weeks  he 
was  able  to  be  up,  and  about,  in  his  usual  good  health. 

Case  Twelve. — Feb.  19,  1893.  Patient,  a truckman,  36 
years  old,  suffering  from  left  inguinal  hernia,  non-strangulated. 
He  had  had  a rupture  for  several  years,  which  he  found,  of 
late,  as  it  came  down,  was  more  difficult  to  return.  When  it 
descended  the  last  time,  it  gave  him  great  pain,  at  which  time 
I was  sent  for.  It  could  not  be  reduced.  As  there  were  no 
serious  symptoms  present,  tentative  expedients  were  resorted 
to,  as  the  patient  was  not  disposed  to  have  an  operation  per- 
formed. 


152  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

The  following  day,  as  the  hernia  yet  remanied  strangu- 
lated, he  was  sent  to  the  hospital,  where  in  the  afternoon,  I 
operated  on  him;  employing  cocaine  analgaesia  locally,  over 
the  operative  areas. 

On  dissection,  an  immence  mass  of  omentum  was  ex- 
posed, which  had  been  tightly  nipped,  at  the  internal  ring. 
This  was  freely  released  and  then  cut  away;  as  far  up  as  possi- 
ble; the  stump  being  preserved  to  obturate  the  portal  of 
escape.  The  parts  were  all  immediately  closed  in,  without 
drainage.  Union  was  prompt  and  his  recovery  uneventful. 
He  left  the  hospital  two  weeks  after  operation;  when  the 
wound  was  well  healed. 

Case  Thirteen. — Patient,  27  years  old,  admitted  to 
hospital  Oct.  20,  1893.  Strangulated  inguinal  hernia  on  the 
left  side. 

The  hernial  mass  was  of  vast  proportions  and  exceedingly 
painful  to  the  touch.  He  had  a hermia  on  this  side,  for  several 
years,  but  always  kept  it  up  with  a truss. 

In  the  morning,  of  September  20,  he  was  suddenly,  and 
without  warning  seized,  while  he  was  walking  on  the  side-walk, 
near  where  he  lived,  with  violent  pain  in  the  hypogastrium. 
At  the  same  time  he  discovered  that  his  hernia  had  come 
down  in  large  volume;  though,  he  had  a truss  on.  The  pain 
was  so  intensely  agonizing  that  he  had  to  make  for  a near 
stoop,  and  rest  on  the  steps.  But,  his  pain  becoming  more 
and  more  severe,  and  his  cries  of  anguish  louder,  a policeman 
was  called,  who  summoned  an  ambulance,  and  sent  him  to  the 
hospital.  He  was  entered  just  before  twelve  o’clock. 

On  admission,  the  general  symptoms  were  very  urgent. 


C O CA1N1ZA  TION  2N  SURGERY  OF  THE  BLADDER.  153 


His  pulse  was  130  per  minute,  and  his  temperature  bounded 
up  to  105 °.  Hypodermic  injections  of  morphine  were  given 
him,  moderate  effects  at  taxis  were  made,  and  iced  applica- 
tions applied,  over  the  large  tumor.  As  it  could  not  be  re- 
duced by  taxis,  and  his  condition  was  becoming  rapidly  worse, 
he  was  prepared  for  operation. 

The  hernial  tumor  was  very  large  and  tense,  with  the 
abdomen  everywhere  hard  and  distended.  Vomiting  was 
almost  continuous,  and  he  constantly  clammored  for  cold 
drinks.  On  exposure  of  the  sac,  under  cocaine  anaesthesia,  a 
very  considerable  extrusion  of  several  coils  of  the  intestine 
was  reached.  These  were  widely  distended  and  their  walls 
intensely  engorged.  At  this  stage  there  was  no  change  in 
color  or  consistence,  of  the  intestinal  coats,  suggestive  of 
gangrene. 

On  opening  the  sac  and  exploring  the  canal,  it  could  not 
be  said,  that  there  was  any  special  point  of  constriction;  but, 
rather  a want  of  correspondence,  between  the  proportions  of 
the  tubular  passages  and  the  escaped  viscera. 

The  bowel  had  been  partly  twisted  on  its  own  axis,  in 
such  a manner,  as  to  render  its  return  quite  impossible;  until, 
this  was  overcome  by  direct  manipulation. 

When  the  intestine  was  exposed  and  the  canal  widened, 
by  freely  dividing  the  inner-pillars  of  the  external-ring,  an 
accident  occured  which  rendered  the  complication  of  the  oper- 
ation very  difficult.  Just  at  this  juncture,  he  was  sized  with  a 
violent  attack  of  retching,  and  forced  down  another  considera- 
ble mass  of  the  intestine.  These  were  quickly  enveloped  in 
warm,  moist  towels.  The  entire  mass  now  so  resisted  manipu- 
lation for  return,  that  it  was  only  by  gradually  emptying  the 


154  LOCAL  ANAESTHETICS  AND  COCAINE  ANALG/E^IA. 


bowels  contents,  gas  and  fluids,  backwards,  into  the  intestine, 
yet  within  the  abdomen,  that  I was  able  to  finally,  reduce  the 
whole  mass;  which  towards  the  end  went  back  with  the  same 
gurgling  sound,  as  in  cases,  wherein,  we  reduced  by  taxis  over 
the  integument. 

He  immediately  ceased  groaning  as  the  hernia  went 
back,  and  expressed  himself  as  greatly  relieved.  The  radical 
operation  was  superadded.  That  evening  his  temperature 
fell  to  990.  In  the  morning  he  had  a large  alvine  evacuation; 
having  slept  well  through  the  night  and  retained  all  the  liquid 
food  given  him. 

On  the  second  day  after  operation,  symptoms  of  general 
peritonitis,  set  in,  and  he  died  the  following  morning. 

A post-mortem  examination,  twenty-four  hours  aftef  death, 
a perforation  of  the  coil  of  intestine  which  had  been  strangu- 
lated was  found,  with  free  escape  of  the  faecal  matter,  into  the 
peritoneal  cavity. 


Comments  on  Cocainization  in  Strangulation  Cases; 

Especially  the  Thirteen  Cases  Here  Reported. 

Although  cocaine  locally  employed  is  the  safest  anaes- 
thetic in  strangulation  cases  of  hernia,  it  may  be  also  utilized, 
in  any  type  of  non-strangulated  hernia,  when  there  are  good 
grounds,  for  rejecting  pulmonary-anaesthetics. 

It  will  be  noted  with  the  list  of  cases,  here  recorded,  that 
since  my  first  operation  for  strangulation,  under  cocaine  anal- 
gaesia,  on  June  7,  1891,  there  has  been  no  death  from  opera- 
tive-shock, in  the  thirteen  cases.  And,  that  of  the  four  deaths, 


COCAINIZATION  IN  SURGERY  OF  THE  BLADDER.  155 


reported,  in  all,  but  Case  Two,  of  strangulated  femoral  hernia 
in  the  aged  female,  the  cause  of  death  could  be  clearly  ac- 
counted for. 

Here,  we  were  left  in  doubt  because  an  autopsy  was  de- 
nied us. 

In  every  instance  except  this  one,  there  was  no  evidence 
that  the  operation  could,  in  any  manner  be  charged,  with  the 
mortality. 

But  in  the  case  of  the  old  lady,  as  she  survived  until  the 
third  day,  it  might  be  assumed  that  the  wound  had  been  in- 
fected, etc.,  in  operation,  and  that  perforation  could  scarcely 
occur,  so  late. 

Mr.  Bowles,  however,  tells  us,  that  we  may  have  perfora- 
tion of  the  bowel,  after  operation  for  strangulation,  as  late  as 
the  tenth  day  ( Lancet , June,  1893,  p.  294). 

In  Case  Thirteen  of  this  series,  it  was  most  remarkable, 
how,  after  a strangulation  of  but  four  hours,  the  intestine  could 
have  sustained  such  damage  to  its  integrity,  as  to  break  down 
and  cut  off  life,  just  at  a time,  when  all  operative  danger  was 
passed.  It  might  be  said,  that  in  this  case,  when  serious  con- 
secutive symptoms  followed,  a laparotomy  should  have  been 
immediately  performed,  and  an  anastomosis  made.  But,  our 
patient’s  condition  was  such  as  to  entirely  preclude  it. 

From  this  last  case  we  witnessed  a renewed  confirmation 
of  what  experienced  operators  have  always  declared,  viz.,  that 
a strangulated  hernia  is  not  always  dangerous,  in  proportion 
to  the  period  of  time,  since  strangulation  set  in,  as  the  quality 
of  the  factors  in  its  cetiology. 

This  we  saw  again  verified,  in  the  case  of  the  young  letter- 
carrier  who  was  incompletely  operated  on,  and  whose  intes- 


156  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

tine  had  been  caught  in  the  internal  ring,  for  nearly  four  days; 
yet,  on  its  release,  he  made  an  excellent  recovery. 

In  these  thirteen  cases  of  operation  for  strangulated 
hernia,  there  were  four  deaths,  or  30.76  per  cent.;  mortality. 

One  death  was  caused  by  rupturing  the  bowel,  by  taxis, 
befere  operation. 

One  death  was  caused  by  gangrene  of  bowel,  in  situ. 

One  death  was  caused  by  consecutive  perforation. 

One  death’s  cause  was  undetermined. 

None  directly  due  to  operation. 


CHAPTER  XXL 


COCAINIZATiON  IN  GENITOURINARY  SURGERY. 


Cocaine  is  at  the  present  time,  largely  employed  in  male 
genito-urinary  surgery. 

Quite  a few  cases  of  mishaps  have  been  reported,  from  its 
use  in  the  urethra.  But,  it  is  my  impression  that  these  acci- 
dents were  rather  attributable,  to  its  abuse  or  mal-administra- 
tion,  than  to  its  toxic  properties. 

No  doubt,  in  not  a few,  it  was  the  result  of  the  peculiar, 
inherent  intolerance  of  the  genital  mucous-membrane,  to  any 
description  of  manipulation. 

The  class  of  lesions,  in  which  it  may  be  utilized  in  genito- 
urinary surgery,  may  be  grouped  in  two  general  divisions. 

First,  in  those  general  lesions  which  involve  the  internal 
parts  and  genital  appendages. 

Secondly,  in  those  which  are  located,  on  any  part  of  the 
vesico-urethral  mucous-membrane,  or  are  caused  by  the  spread 
of  an  infection,  into  the  contiguous  parts. 

Of  the  first,  may  be  enumerated,  operations  on  the  pre- 
puce; for  phymosis,  paraphymosis,  or  circumcision. 

For  the  treatment  of  spermatic  varices;  for  the  radical 
cure  of  hydrocele,  or  all  other  operations  on  the  scrotum  or 
testis,  except  perhaps,  castration. 

— 157 — 


158  LOCAL  AN  AES  THE  TICS  AND  COCAINE  ANALGESIA. 

Cocainization  is  generally  more  valuable  in  operations  or 
manipulations  which  involve  the  urethra. 

When  properly  employed,  it  is  of  great  value  in  treating 
stricture,  whether  we  select  gradual  dilatation,  divulsion,  or 
incision.  When  we  propose  to  employ  it  for  these  latter  pur- 
poses internally,  we  should  first  cleanse  the  urethra  carefully, 
with  a warm,  weak  antiseptic  solution.  Then,  the  urethra 
should  be  emptied  as  completely  as  possible,  when  we  are 
ready  for  cocainization.  If  our  patient  have  a tight  stricture, 
we  need  have  no  fears  of  any  of  the  solution  reaching  the 
bladder. 

It  has  been  my  custom,  to  use  only  a one  per  cent,  solu- 
tion; injecting  into  the  urethra  from  one  to  two  drams;  after 
which,  the  glans  penis  is  seized  and  the  urethra  so  compressed, 
that  the  solution  will  come  in  contact,  with  the  deep  and  su- 
perficial portions  of  it. 

This  kneading  is  continued  for  one  or  two  minutes,  when 
we  milk  the  urethra  empty,  of  all  the  residue  of  the  analgaesic. 

Now  we  are  ready  to  proceed  with  instrumentation.  By 
this  plan  the  most  sensative  urethra  is  made  tolerant.  Andr 
although  the  pain-sense  is  annulled,  yet,  the  patient  is  con- 
scious of  the  passage  of  a bougie  or  other  instrument,  and 
knows  when  it  has  engaged  in,  or  passed,  the  stricture. 

By  this  method,  I have  succeeded  with  the  greatest  ease,, 
in  completely  divulsing  or  cutting  a tight  stricture,  at  one  sit- 
ting, without  any  assistant,  and  with  the  most  satisfactory 
results. 

It  is  of  no  aid  in  those  strictures,  wherein  we  treat  them, 
by  gradual  dilation;  and,  in  which  the  urethra  is  amply  tolerant. 

Accordingly,  when  we  employ  it,  we  should  enjoin  the 


C0CAIN1ZATI0N  IN  GEN1TO-URINARY  SURGERY. 


159 


same  severe  regimen,  rest  and  after  treatment,  as  we  would 
when  a general  anaesthetic  is  employed. 

As  I have  had  no  experience,  in  the  treatment  of  vessical 
lesions,  through  the  urethra  with  it,  I am  unable,  to  say,  what 
the  role  of  cocaine  is,  here.  There  have  been  good  reports 
from  it,  when  so  employed;  but,  no  doubt,  in  all  cases,  if  we 
would  avoid  its  dangers,  we  must  be  certain,  that  the  residue 
of  the  solution  is  completely  cleared  from  the  bladder,  before 
any  operation  is  undertaken. 

When  the  glands  of  the  groin  are  infected  from  venereal 
poison,  cocaine-hypodermication  will  enable  us,  to  painlessly 
and  freely  incise  the  enclosing  envelopes,  gouge  away  the 
necrotic  remains,  drain  and  close  in  the  parts. 

In  operations  on  the  urethra  for  traumatic  ruptnre,  or 
perineal  abscess,  by  this  agent,  we  may  in  most  cases  rapidly 
and  successfully  deal  with  them. 

In  large  cancerous  ulcers  of  the  glands,  if  we  propose  to 
destroy  them  by  free  cauterization;  by  first  cleansing  them, 
and  then,  applying  over  their  nude  surface,  a pledget  of  cotton 
imbibed  with  a four  per  cent  solution  of  cocaine,  which,  without 
it  is  attended  with  great  torture,  is  now  devoid  of  all  suffering. 


C H A H T E R XXII. 


COCAINIZATION  IN  GYNyECOLOICAL  SURGERY. 


The  field  for  cocaine,  in  minor  gynaecological  operations, 
is  a large  and  ever  growing  one. 

In  a general  way,  it  may  be  said,  that  it  will  suffice  for 
all  plastic  operations,  on  the  urethra  and  vagina.  I have  never 
employed  it,  in  but  one  case  of  abdominal-gynaecology.  This 
was  in  an  operation,  for  a cystic  growth  in  the  broad  ligament. 
It  was  unsatisfactory,  and  my  patient  succumbed  from  peri- 
tonitis, on  the  fourth  day. 

For  intra-uterine  operations;  cervical-dilatation,  grattage 
of  the  mucosum,  for  the  removal  of  polypoid  neoplasms,  or, 
for  the  excision  of  the  cervix,  it  fulfills  all  demands  and 
greatly  simplifies  all  those  procedures. 

In  the  opening  chapters  of  this  monograph,  it  was  stated 
that  cocaine  was  not  generally  satisfactory,  when  used  in  oper- 
ations on  females. 

This  holds  good  in  general;  but,  in  all  the  gynaecological 
operations,  in  which  I have  employed  it,  there  has  in  no  in- 
stance, been  the  slightest  mis-adventure.  This  seems  to  me 
to  be  a singular  clinical  fact;  which  has  no  analogy,  except,  in 
the  case  of  chloroform,  which,  when  employed  to  secure  euthan 
asia  in  labor,  seldom,  or  never  is  the  cause  of  serious  accident. 


—160— 


C0CA1N1ZA  TION  IN  GYNECOLOGICAL  SURGERY.  161 


I have  repeatedly  operated  for  laceration  of  the  cervix, 
and  the  vagina  with  cocaine  injections;  besides  treated  vesico- 
vaginal and  recto-vaginal  fistula,  dilated  the  cervix,  curretted 
the  uterus,  and  delivered  large,  sessile  and  pedunculated 
fibrous  polypi,  with  the  same  agent;  and  never,  with  any  mis- 
hap. The  cancerous  cervix  has  been  drawn  down  into  the 
vagina,  and  its  ulcerating  border  completely  cleared  away  with 
the  knife,  the  patient,  at  no  time  suffering  pain,  or  any  draw- 
back which  interfered  with,  at  least,  temporary  recovery. 

Cocainization  is  much  more  rapid  and  effective  here,  than 
in  many  other  situations;  because,  we  use  it  conjoinedly,  by 
injection,  and  on  the  surface,  at  the  same  time. 

In  many  cases,  we  will  secure  quite  deep  surface  anal- 
gaesia  of  a mucous-membrane,  by  freely  mopping  it,  for  a 
moment,  with  a four  per  cent  solution.  When  our  operation 
is  to  be  delicate  and  tedious,  and  our  incisions  are  to  penetrate 
deeply,  it  will  be  more  secure,  to  inject  a certain  quan- 
tity of  a one  per  cent.,  solution,  into  the  sub-mucous  tissues. 
It  will  be  necessary  to  observe  in  all  these  cases,  that  we  have 
used  the  medicament,  on  the  surface,  but,  a much  diminished 
dosage  need  be  injected. 

Those  painfull,  vascular  papillary  masses  which  are  some- 
times clustered  about  the  female  urethra;  the  so-called  carunc- 
ulae,  may  be  radically  treated  by  excision  without  the  least 
pain,  by  the  simple  swabbing  of  their  surface,  with  a cocaine 
solution.  Indeed,  the  number  of  local  diseased  conditions  so 
common,  about  the  urethro-vulva-vaginal  outlet  is  so  large,  in 
which  cocaine  will  entirely  displace  ether,  that  the  limits  of  this 
contribution,  will  not  permit  of  their  enumeration  and  descrip- 
tion. 


CHAPTER  XXIII. 


COCAINIZATION  IN  THE  SURGERY  OF  ANO- 
RECTAL DISEASES. 


In  divers  contributions  in  current  American  medical  litera- 
ture, there  have  been  presented  some  of  my  experience  with 
the  local  use  of  cocaine  in  ano-rectal  diseases. 

My  first  attention  was  attracted  to  cocaine-analgsesia,  by 
what  I had  seen  accomplished  by  it  in  the  Parisian  Hospitals. 
In  the  Hotel  Dieu,  I first  saw  M.  Ricard  employ  cocaine 
hypodermically,  as  an  analgaesic,  in  the  treatment  of  h?emor- 
rhoids. 

The  anus  and  rectum  were  first  thoroughly  cleansed, 
when  the  cocaine  solution  was  applied.  With  a peculiarly 
constructed  speculum,  which  served  the  purpose  of  enabling 
one  to  inspect  the  rectum,  at  the  same  time,  by  a circular  and 
see-saw  movement,  severely  compress  the  haemorrhoidal  mass. 
After  this,  species  of  painless  crushing  was  completed,  the 
parts  were  again  sponged.  Now,  the  patient  left  the  table 
and  went  on  about  his  business. 

The  operator  assured  his  audience,  that  by  this  very  sim- 
ple measure,  of  anal-dilatation  and  compression,  the  patient 
could  at  once  resume  his  usual  employment,  and  that  it  gen- 
erally cured  him.  This  simple,  painless  and  radical  operation 


—162— 


COCAIN/ZA  TION  IN  SURGERY  OF  THE  RECTUM.  163 


for  haemorrhoids,  struck  me,  as  an  enormous  improvement  over 
the  older,  bloody  and  often  unsatisfactory  methods,  commonly 
in  vogue. 

Having  carefully  considered  the  advantages  and  disad- 
vantages of  this  scheme,  I finally  decided  to  fully  test  its 
efficacy,  on  my  return  home. 

After  a very  short  experience  with  it,  enough  was  seen  to 
strongly  convince  me,  that  for  treatment  of  non-bleeding  haem- 
orrhoids, internal  or  external,  it  was  the  most  useful,  of  any 
method  yet  devised. 

It  is  bloodless,  and  painless;  there  is  no  danger  of  second- 
ary-haemorrhage, infection,  suppuration  and  fistulae,  as  may 
occur,  after  any  of  those  operations  which  entail  cutting,  caus- 
tics or  the  ligature. 

As  there  are  no  pulmonary-anaesthetics  employed,  their 
dangers  are  entirely  obviated.  As  there  is  no  mutilation  and 
no  large  open  wound  to  heal,  the  operation  makes  but  little 
impression,  on  the  constitution;  and,  no  long,  tedious  convales- 
cence follows. 

With  but  a slight  modification  on  Ricard’s  plan,  I now 
treat  all  simple  cases  of  simplex  piles.  Instead  of  compressing 
the  haemorrhoids  with  an  instrument,  I crush  each  tumor,  within 
its  coats,  with  the  index  finger  and  thumb;  besides,  twist  and 
stretch  its  pedicle,  before  its  return  within  the  syhincter. 

Cocainization  will  answer  equally  well,  with  the  most 
complicated  as  well  as  simple  cases,  though,  our  technique  of 
operating  is  not  the  same. 

It  has  answered  admirably  with  me,  in  cases  of  fistulae, 
fissure,  condylomata  and  superficial  epithelioma;  of  the  lower 
segment  of  the  rectum. 


164  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGAESIA. 

The  technique  for  efficient  local  analgaesia  in  ano-rectal 
operations  is  essentially  the  same,  as  for  operations,  in  the 
vaginal  outlet,  except,  that  as  this  district,  when  diseased,  is 
exceedingly  sensative,  to  any  sort  of  manipulation,  it  is  im- 
portant, that  every  detail  in  administering  the  analgaesia  must 
be  carried  out,  in  all  its  minutiae. 

The  day  before  operation,  the  intestinal-tract  should  be 
freely  cleared  with  a brisk  purgative. 

Our  patient  should  be  mildly  inebriated,  if  possible.  Now, 
being  placed  on  his  back,  in  a good  light,  we  first  scrupuously 
cleanse  the  perineum  and  shave  the  entire  district  about  the 
anus.  We  will  then  request  the  patient  to  bear  down  gently, 
which  will  partly  unfold  the  anal  rugae  and  turn  out  the  lower 
haemorrhoids.  These  are  sterilized  and  dried;  when  we  apply 
a four  per  cent.,  solution  of  cocaine,  very  lightly  at  first;  then 
more  freely,  pressing  the  moistened  cotton  up  to,  and  against 
the  external  sphincter  for  a moment.  This  will  permit  of  the 
introduction  of  the  warm,  lubricated  index  finger  of  the  left 
hand.  This  is  pressed  in  gently  to  the  webbing  of  the  hand 
and  fixed.  The  surface  is  now  flushed  again,  when  the  hypo- 
dermic-needle is  taken  in  hand.  Now,  the  index-finger  in  the 
rectum  is  so  bent,  as  to  form  a hook,  when  the  largest  haemor- 
rhoid is  so  pressed  against  the  anus,  that  the  point  of  the  hypo- 
dermic-needle can  penetrate  it  and  deposit  one  or  two  drops 
of  a one  per  cent.,  solution  directly  into  its  center. 

This  is  repeated  with  each  successive  large  haemorrhoid, 
until,  they  are  well  inhibited  to  pain. 

I make'  but  four  hubs  and  employ  from  seventy-five  to 
one  hundred  drops  by  the  syringe. 

Cocainization  complete,  the  external  spincter  is  widely 


C0CAIN1ZATI0N  IN  SURGERY  OF  THE  RECTUM.  165 


and  completely  dilated.  This  part  of  the  operation  is  indes- 
pensible;  for,  without  it,  it  will  be  impossible  to  manipulate  the 
internal  parts,  and  the  results  will  be  very  unsatisfactory.  But, 
in  an  old  chronic  case,  in  which  the  sphincter  has  wasted  in 
muscle  substance,  and  it  has  an  unyielding,  resisting. feel,  we 
must  make  our  distension  very  gradually  and  with  caution,  or 
we  will  lacerate. 

The  sphincter  well  dilated,  we  will  easily  roll  out  the 
haemorrhoids.  Now,  their  surface  is  again  irrigated  and  dried, 
when  the  surface  of  all  is  once  more  lightly  swabbed  with  a 
four  per  cent.,  solution  of  cocaine.  At  this  stage  of  the  opera- 
tion, each  haemorrhoid  is  taken  separately  and  crushed  with 
sufficient  force,  to  thoroughly  break  down  all,  but  the  external 
fibro-serous  coat.  This  is  done,  as  remarked  previously,  with 
the  thumb  and  fingers  of  the  right  hand. 

I designate  this,  pressure-massage.  After  being  crushed, 
each  tumor  is  severely  twisted  on  its  base  and  stretched. 
When  this  is  systematically  effected  with  each  haemorrhoid, 
the  whole  mass  is  turned  back,  within  the  sphyncter,  a sup- 
pository of  opium  is  introduced  and  a pad-support  applied  to 
the  anus,  with  a T bandage  to  support  it.  This  completes  the 
operation. 

In  cases  of  internal  haemorrhoids  or  vascular  papillomata 
of  the  rectum,  this  sort  of  local  anaesthesia  equally  suffices. 

Not  long  since,  I was  requested  to  operate  on  a case  of 
complicated,  internal,  bleeding  and  external  piles,  for  Dr.  J.  M. 
F.  Egan  of  this  city.  The  patient  was  a young  married  man, 
who  was  greatly  exsanguinated,  by  the  continued  loss  of  blood, 
with  each  movement  from  the  bowel. 

In  this  case,  after  sufficient  cocainization  and  dilatation. 


166  LOCAL  ANESTHETICS  AND  COCAINE  ANALGESIA. 

the  small,  vascular,  fungoid  masses  were  each  separately 
freely  touched,  with  the  thermo-cautery.  Besides,  each  large, 
haemorrhoidal  tumor  was  seized,  and  treated  in  the  usual 
manner.  The  patient  at  no  time  experienced  any  pain,  and 
the  performance  of  the  operation  occupied  only  a lew  moments. 

Five  years  ago,  for  the  first  time,  I saw  cocaine  employed 
as  a local  anaesthetic,  by  my  friend  Dr.  T.  J.  McGillicuddy,  of 
this  city,  in  the  treatment  of  rectal  fistula.  In  simple,  non- 
complicated  cases,  since  that  time,  of  rectal  fistula  and  fissure, 
I have  seldom  employed  anything  else.  In  any  deep,  ex- 
cavating, ischio-rectal  sinuses,  which  require  an  extended  dis- 
section, we  cannot  rely  on  cocaine,  but,  these  are  unusual,  and 
when  encountered,  they  may  be  in  those,  who  are  the  sub- 
jects of  pulmonary  tuberculosis,  on  whom,  the  propriety  ot 
any  operation  may  be  questioned.  The  rest  which  we  can 
secure,  after  operation,  on  the  rectum,  by  cocaine,  the  absence 
from  vomiting,  retching  and  struggling;  and  the  clean,  clear 
field  for  operation  without  the  parts  being  besmeared  by 
faeces,  in  the  course  of  operation,  are  a great  gain. 

No  accident  ever  happened,  in  any  of  my  rectal  opera- 
tions, under  cocaine,  except,  in  one  instance.  A young  man 
came  to  me  complaining  of  the  most  intense,  distressing  pain 
in  the  anus,  with  a bunch  of  highly  inflammed  hemorrhoids, 
partly  projecting  though  the  sphyncter.  He  was  placed  on 
his  back,  and  a pledget  of  cotton  which  had  imbibed,  about  a 
dram  of  a four  per  cent  solution,  was  lodged  just  inside  the 
rectum. 

I noticed  that,  in  a moment  he  became  deathly  pale,  and 
the  radial  pulse  was  almost  imperceptible.  In  a moment  I 
hastily  removed  the  cocainized  cotton;  but,  it  was  too  late, 


COCAINIZA TION  IN  SURGERY  OF  THE  RECTUM.  167 


my  patient  was  suddenly  taken  with  the  most  alarming  symp- 
toms, and  declared  he  was  dying.  He  was  given  brandy 
freely  by  the  mouth,  and  strong  ammonia  was  placed  under 
his  nostrils.  The  face  was  douched  with  cold  water;  hot  ap- 
plications were  placed  over  the  heart,  and  the  body  was  freely 
rubbed.  After  about  ten  minutes  he  commenced  to  react,  and 
in  a little  while  he  was  able  to  return  home,  in  a coach.  This 
accident  taught  me  the  useful  lesson,  of  never  leaving  a satu- 
rated sponge  or  piece  of  cotton,  again,  in  immediate  contact 
with  a mucous  membrane,  over  any  extended  period  of  time, 
unless,  the  cocaine  solution  is  very  feeble. 


CHAPTER  XXIV. 


COCAINIZATION  IN  THE  SURGERY  OF  THE 
LOWER  EXTREMITIES. 


Except,  for  those  peripheral  neoplasms  which  occupy  the 
various  planes  of  the  thigh  and  leg,  cocainization  is  not  of 
general  application.  But,  there  are  exceptional  conditions  in 
the  parts  more  deeply  lodged;  wherein,  it  might  serve  a useful 
purpose.  Of  these  may  be  mentioned,  the  deligation  of  the 
femoral  artery,  in  Scarpa’s  triangle,  for  aneurism.  Here,  the 
vessel,  though  commonly  an  inch  from  the  surface,  is  readily 
reached,  and  lies  imbedded  in  an  atmosphere  of  cellular  and 
adipose  tissue,  only. 

Very  generally,  a popliteal  aneurism,  when  not  of  a trau- 
matic origin,  is,  but  a local  expression  of  a general  degenera- 
tive atheroma  of  the  entire  arterial  system;  or,  at  all  events, 
certain  sections  of  it,  which  may  supply  various  organs,  vital 
to  life;  particularly  the  brain. 

It  is  clearly  manifest,  that  under  these  circumstances,  any 
general  anaesthetic,  which  entails  excessive,  vascular  distention 
of  diseased  arteries,  must  needs  greatly  add  to  the  dangers  of 
an  operation,  performed  under  its  employment.  No  doubt,  in 
cases,  heretofore  set  down,  as,  “death  from  shock  or  sup- 
pression of  the  urine,”  after  a simple  bloodless  operation;  the 


—168— 


C0CAIN1ZAT10N  IN  SURGERY  OF  LOWER  EXTREMITIES.  169 


underlying,  fundamental  factor  has  been  chloroform  or  ether 
toxemia.  Hence,  in  this  class  of  cases,  that  a local  analgsesic, 
when  it  can  be  effectually  utilized,  offers  great  advantages  over 
any  other;  in  which,  the  circulation  is  charged  with  a lethal 
substance,  and  serious  vaso-motor  disturbances,  are  almost 
certain  to  follow. 


COCAINIZATION  IN  TENOTOMIES. 

Those  tendons  which  lie  near  the  surface,  as  the  ham- 
strings, tendo  Achillis,  the  anterior  and  posterior  tibial,  and 
others,  by  the  utilization  of  cocaine,  may  be  painlessly  divided. 
But,  as  in  most  cases  requiring  tenotomies,  other  manipulative 
procedures,  must  be  superadded,  which  may  give  rise  to  great 
pain  and  occupy  considerable  time,  unless,  there  are  serious 
dangers  involved,  justice  to  our  patient  requires  us,  to  give 
pulmonary  anaesthetics. 


Coca i n i zation  in  the  Surgery  of  the  Foot. 

Toe-amputations  may  be  carried  out  under  cocaine  anaes- 
thetics; in  traumatic  cases  with  perfect  satisfaction.  But,  with 
irritable  or  very  young  patients,  in  pathological  conditions,  it 
may  be  better,  to  give  ether. 

Cocaine  serves  an  admirable  purpose,  in  the  avulsion  of 
an  in-growing  toe-nail. 

This  is  a common  and  very  painful  condition;  for  which, 
many  palliative  operations  and  schemes  of  treatment,  have 
been  devised. 

But,  there  is  none  so  promptly  and  radically  curative,  as 


170  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGESIA. 

the  total  avulsion  of  one  half,  or  the  entire  nail;  according,  as 
to  whether  one,  or  both  borders  of  the  matrix,  is  involved  in 
the  ulcerative  process. 

The  toe  is  prepared  for  operation,  by  a thorough  cleans- 
ing, down  to  the  webbing. 

It  is  now,  isolated,  by  enveloping  the  entire  foot,  in  a 
sterilized,  gauze  material  and  bandage.  As  the  parts  here  are 
so  extremely  sensative,  and  the  operative  area  of  narrow  pro- 
portions, I make  an  exception,  and  employ  a four  per  cent, 
solution  of  cocaine.  Everything  being  ready,  the  foot  is  placed 
on  the  operator’s  knee,  while  the  patient  sits  up. 

The  great-toe  is  seized  firmly  between  the  thumb  and  the 
fingers  of  the  left  hand,  when  the  charged  syringe  is  taken  in 
hand,  and  the  needle  sent  in,  under  the  nail,  on  a line  which 
passes  through  the  center  of  it.  The  point  is  sent  down  to, 
and  about  half  a line,  below  the  matrix.  Now,  it  is  arrested, 
when  one  or  two  drops  of  the  solution  is  deposited. 

The  needle  is  then  withdrawn,  to  within  one  or  two  lines 
of  entrance;  in  the  meantime,  its  path  having  been  sprayed 
with  from  three  to  five  drops  of  the  solution. 

Now,  without  withdrawing  the  needle’s  point,  it  is  sent  in, 
at  an  obtuse  angle,  on  the  inner  side,  withdrawn,  and  sent  in 
again,  in  the  same  manner,  on  the  external  side;  in  the  mean- 
time, the  needle-path  being  sprayed  each  time,  as  in  the  pri- 
mary puncture;  in  other  words,  we  make  but  “one  hub  and  three 
spokes.” 

All  this  is  but  the  work  of  a moment,  when  we  are  pre- 
pared to  split  the  nail  in  two  separate  discs;  by  carrying  the 
blade  of  the  scissors  down^to  the  bottom  of  it,  and  a little 
beyond  its  matrix.  At  this  stage,  with  a heavy,  strong  for- 


COCAINIZA  1 ION  IN  SURGER  Y OF  LOWER  EXTREMITIES.  171 


ceps,  each  half  of  the  nail  is  torn  completely  out  of  its  bed,  on 
one  or  both  sides.  Ordinary  dressings  are  applied,  and  the 
case  dismissed  for  the  time. 

But  a few  days  since,  a young  gentleman  came  to  me, 
with  double  inversion  of  the  borders  of  the  nail,  of  the  great- 
toe.  For  months,  palliative  measures  had  been  employed, 
but,  with  only  temporary  relief.  He  winced  only,  when  the 
needle  first  went  in.  After  the  first  drop  of  cocaine  had  been 
deposited,  he  had  no  more  sensation,  than  though  it  were  a 
dead  substance. 


CHAPTER  XXV. 


COCAINIZATION  IN  MISCELLANEOUS 
OPERATIONS. 


The  general  practitioner,  in  a suburban  village  or  country 
practice,  should  always  carry  about  his  person,  the  wherewith 
to  induce  cocainization,  at  a moment’s  notice;  which  means 
simply,  that  he  will  have  in  his  pocket-medicine-case,  a place 
for  a few  tablets  of  pure  hydrochlorate  of  cocaine. 

A hypodermic  case  is  now  a-days,  a necessary  part  of 
one’s  ambulatory  arsenal. 

Armed  with  the  few  and  inexpensive  implements  required, 
to  induce  cocainization,  he  will  always  be  impressed  with  a 
sense  of  safety;  and  will  be  able  to  perform  painlessly  and 
promptly,  many  operations,  which  he  might  otherwise  be 
obliged  to  neglect,  and  permit  a continued  suffering,  or  even 
death  itself,  in  not  a few  cases. 

As  a general  rule,  when  one  gets  into  a certain  rut,  or 
routine  practice,  it  requires  often  considerable  determination 
and  effort,  to  get  out  of  it. 

In  the  near  past,  it  has  been  too  common  a practice,  to 
etherize  for  everything;  as  though,  it  were  totally  devoid  of 
danger,  and  furthered  the  patients  prospects,  in  the  way  of 
recovery. 


—172— 


COCAINIZA  TION  IN  MISCELLANEOUS  OPERATIONS.  173 


But,  the  infliction  of  moderate  pain,  in  numerous  condi- 
tions is  salutary  and  necessary  to  relief.  There  are  some 
patients  who  are  immune  to  the  action  of  cocaine;  or,  so  resist, 
that  its  full  effects  cannot  be  realized;  while  on  the  contrary, 
there  are  others,  who  are  more  morbidly  susceptible  to  it. 
With  the  former,  if  we  will  amply  fortify  our  patient  with 
alcoholics,  no  harm  will  follow,  and  the  pain  inflicted  will  be 
slight. 

For  the  latter,  unhappily  there  is  no  reliable  prophylactic, 
when  very  grave  symptoms  arise;  except,  through  the  action 
of  powerful  stimulants;  but,  if  we  restrict  the  dose  within  a safe 
limit,  and  are  not  tempted  to  go  far  beyond  it,  we  are  practi- 
ally  safe,  from  accident. 

The  scope  and  purpose  of  this  monograph  will  not  per- 
mit of  a description  of  all  the  lesions,  of  the  body  in  which 
cocaine,  will  serve  as  a valuable  substitute  for  ether  or  chloro- 
form; nor  is  it  necessary;  for,  after  one  has  given  it  a few  fair 
trials,  it  will  soon  be  apparent,  what  its  limitations  are. 

But,  it  may  be  well  to  remember,  that  effective  cocainiza- 
tion  has  a technique,  which  must  be  mastered.  Without  this, 
our  results  will  be  very  unsatisfactory,  and  the  drug  will  be 
condemed  and  cast  aside  in  disgust. 

It  is  my  firm  conviction,  that  when  the  art  of  properly 
administering  cocaine  as  an  inhibitor  of  the  pain-sense  is 
mastered,  and  its  virtues  are  more  generally  appreciated,  the 
mortality  after  operations  will  be  enormously  lessened,  and 
pulmonary  anaesthetics  will  be  employed,  only  in  protracted 
capital  operations. 

Antiseptic  and  aseptic  agents  have  enormously  extended 
the  operative  field,  and  eliminated  the  chances  of  infection. 


174  LOCAL  ANALS  THE  TLCS  AND  COCALNE  ANALGALSIA. 

Now,  if  time  will  prove  that  a local  anaesthetic  has  been  dis- 
covered, which  will  obviate  the  dangers  attending  or  follow- 
ing, the  administrating  of  ether  or  chloroform,  the  advance 
will  be  along  the  whole  line,  and  we  may  rest,  content,  that 
science  has  brought  the  art  of  operative  surgery,  to  a very 
high  degree  of  perfection. 


CHAPTER  XXVI. 


MIXED  ANAESTHESIA,  OR  THE  EMPLOYMENT 
OF  PULMONARY-ANaESTHETICS  AS 
AN  ACCESSORY  IN  LOCAL 
ANALGaESICS. 


With  all  our  cases,  in  which,  we  propose  to  employ  local- 
anaesthetics,  it  is  important  to  deliberate  carefully,  on  the 
leading  features  of  the  operation,  about  to  be  undertaken,  the 
difficulties  and  dangers  which  may  attend  it,  and  the  time 
which  it  will  consume  in  its  performance;  besides,  we  should 
endeavor  to  gauge  our  patients  susceptibility.  If  they  are  of 
the  irritable,  cranky,  faultfinding  class,  the  practitioner  will 
act  with  the  best  judgment,  if  he  takes  no  chances,  and  admin- 
sters  to  the  patient  such  an  anaesthetic,  as  his  friends  prefer. 

Cocaine  is  chiefly  recommended,  as  a substitute  for  pul- 
monary-anaesthetics, because,  it  is  a life-saving  agent,  and  be- 
cause in  a vast  number  of  very  painful,  but  trifling  conditions, 
from  an  operative  stand-point;  it  enables  us  to  painlessly  explore 
and  treat  them,  without  putting  the  patient’s  life  in  jeopardy, 
as  we  do.  every  time  anaesthesia  is  carried  to  full  coma. 

Now,  if  one  is  so  unreasonable,  as  to  loudly  complain  of 
the  pain  of  a hypodermic-puncture,  then,  we  should  not  in- 


% 


176  LOCAL  ANAESTHETLCS  AND  COCAINE  AN  ALGAL  SI  A . 

commode  ourselves  for  him,  but  give  him,  with  a free  hand, 
the  more  lethal  agent. 

There  are  cases  however,  in  which,  when  our  patient  is 
not  refractory  we  may,  on  account  of  some  unforseen  difficulty, 
or  unavoidable  delay,  be  obliged  to  resort  to  a pulmonary- 
anaesthetic, 

These  are  an  untoward  class;  and  the  emergency  is  one 
which  calls  for  special  alertness,  on  the  part  of  the  anaesthetizer. 

In  all  cocaine-operations,  it  is  of  prime  importance,  that 
the  patient  partake  freely  of  a hearty  meal,  if  he  be  of  robust 
health. 

A surgeon  who  is  about  to  undertake  anything,  in  the 
nature  of  a difficult  operation,  besides,  preparing  himself  by 
ample  study  and  reflection,  should  be  in  good  physical  form; 
and  the  sooner  he  operates  after  a substantial  meal,  the  better. 
He  certainly  should  not  undertake  a formidable  operation  on 
an  empty  stomach,  or  when  oppressed  by  a sense  of  weariness. 

Similarly,  our  patient  for  the  local  aesthetic,  should  be 
in  good  tone,  and  besides,  have  his  resisting  powers  reinforced, 
by  bracing  doses  of  an  alchoholic. 

Now,  in  pulmonary-anaesthesia  on  the  contrary,  the  more 
hungry  and  weaker  our  pa|ient,  the  more  promptly  will  the 
chemicals  act. 

In  fact,  it  is  this  impaired  physical  candition  which  un- 
doubtedly adds  to  their  dangers. 

But,  the  full  stomach  adds  great  danger  in  ordinary  cir- 
cumstances, to  the  administration  of  ether.  Nature  resists 
the  toxic  action  of  it,  first,  by  a free  emesis;  so  that,  perhaps 
at  a stage  of  the  operation,  when  perfect  quiet  is  most  im- 


MIXED  ANAESTHESIA. 


177 


perative,  every  muscle  is  thrown  into  spasmotic  contractions. 
Besides,  if  great  caution  is  not  observed,  the  vomited  ejecta 
may  be  sucked  into  the  bronchial  tubes,  so  as  to  induce  im- 
mediate suffocation;  or,  if  this  be  escaped,  a septic  pneumonia  . 
may  perchance  follow,  and  cut  off  our  patient,  when  all  danger 
of  operative  manipulation  is  past. 

When  therefore,  etherization  must  follow  cocainization, 
more  than  ordinary  precautions  must  be  observed  in  its  ad- 
ministration, and,  it  should  not  be  resorted  to  at  all,  unless,  in 
cases  of  great  urgency,  which  will  admit  of  no  other  ex- 
pedient. 


ihstidieik. 


Pulmonary  anaesthetics,  danger  to  life,  ....  9 

Pulmonary  anaesthetics,  chemical  purity,  etc.,  ...  10 

Investigation  by  Commission  of  British  Medical  Association,  n 

Death  under  chloroform,  .......  1 1 

Ether  poisoning,  ........  ri 

Cases,  traumatic  and  pathological  .....  n 

Ether,  number  of  deaths  irom  ......  11 

Mortality  from  ether,  .......  12 

Chloroform,  mortality  from  ......  12 

Commission  British  Medical  Association,  ...  12 

Ether  toxaemia,  ........  12 

Haemorrhage  and  shock  as  idiosyncrasies,  Role  in  anaes- 
thesia,   : 13 

Reflex  phenomena,  mortal  ......  13 

Shock,  mental  .........  14 

Military  surgery,  ........  14 

Pathological  conditions,  .......  15 

Elimination  defective,  .......  15 

Renal  organs,  .........  15 

Anaesthetic  agents  and  children,  .....  15 

Opium  narcotic,  mortal  dose  ......  16 

Condition  of  blood,  before  and  after  ether  anaesthesia,  . 17 

Nitrous  oxide,  ........  18 

Antiquity  of  anaesthetics,  .......  18 

Ether  spray,  .........  18 


—179— 


180  LOCAL  ANAESTHETICS  AND  COCAINE  ANALGASIA. 


Distinction  between  an  anaesthetic  and  an  analgaesic,  . 19 

Limited  application  of  frigorific  agents,  ....  20 

Discovery  of  cocaine  anaigaesia,  .....  20 

Gangrene  following  intense  freezing,  ....  20 

Cocaine’s  action  on  mucous  membranes,  ...  21 

Cocaine  subcutaneously  applied,  .....  21 

Annihilation  of  pain  sense.  ......  21 

Coming’s  method  of  prolonging  anaigaesia,  ...  21 

Duration  of  cocaine  anaigaesia,  .....  21 

Local  and  constitutional  action  of  cocaine,  ...  22 

Cocaine’s  similarity  to  morphine’s  chemical  action,  . . 22 

Cocaine,  administration  of  ......  22 

Cocaine,  toxic  action  of  ......  22 

Local  anaesthesia,  when  it  should  be  preferred  . . 23 

Mechanical  anaesthesia,  .......  25 

Thermal  anaesthesia,  .......  26 

Cold  in  finger  amputation,  ......  27 

Ether  evaporation,  ........  27 

Alcoholic  stimulants  as  accessories  in  local  anaigaesia,  . 28 

Pseudo-anchylosis,  ........  28 

Hydropathist  or  “natural  bone-setter,”  ....  29 

Neuritis,  traumatic  ........  31 

Anchylosis,  fibrous  ........  33 

Anchylosis  of  hip,  ........  34 

Anchylosis  of  ankle,  .......  36 

Germicidal  potency  of  low  temperature,  ....  37 

Thermo  therapeutics,  .......  38 

Processes,  chemical  and  vital  ......  38 

Osteo-myelitis,  ........  39 

Patients  refractory  to  anaesthesia,  .....  40 

Ether  as  a local  anaesthetic,  ......  41 

Mixture  of  ice  and  salt,  .......  42 


INDEX. 


381 


Discovery  of  the  local  effects  of  cocaine,  ....  44 

Ether  shock,  .........  46 

Lethality  of  chloroform,  ^ 46 

Anaesthetics  and  analgaesics  of  American  origin,  . . 46 

Adoption  of  cocaine  in  general  surgery  by  Reclus.  . 47 

Phenate  of  cocaine,  ........  48 

Administration  of  alcoholics,  ......  52 

Lethal  action  of  cocaine,  manifested  through  cerebral  and 

cardiac  organs  ........  52 

Hubs  and  spokes,  ........  55 

Coming’s  method,  ........  56 

Inflamed  parts,  ........  57 

Time  to  operate,  . ......  57 

Twenty  per  cent  solutions  into  the  urethra,  ...  58 

Cocaine  in  females  and  children,  .....  59 

Insanity  following  surgical  operations,  ....  63 

Lauder  Brunton  on  cocaine,  ......  64 

Le  Fort’s  fraction  of  tongue  in  asphyxia,  ....  65 

Cerebral  hyperaemia  and  pulmonary  anaesthesia,  . . 6S 

Esmarch’s  bandage  in  skull  surgery,  ....  69 

Debridement  for  trepanage,  ...  . . 70 

Compound  fracture  of  the  skull,  .....  72 

Gunshot  wound  of  frontal  bone,  .....  74 

Cocaine  analgaesia  in  lesions  of  the  skull,  ...  75 

Cocaine  analgaesia  in  mastoid  abscess,  ....  76 

Cocainization  in  haematomata,  etc.,  of  the  scalp,  . . 78 

Cocainization  as  an  aid  in  diagnosing  skull  injuries,  . 80 

Application  of  cocaine  in  the  ocular  region,  ...  82 

Cocainization  in  removing  foreign  bodies  from  the  cornea,  83 

Cocainization  in  the  nasal  and  buccal  cavities,  ...  83 

Cocainization  in  epithelioma  of  the  lip,  ....  85 


182  LOCAL  ANAS  THE  TICS  AND  COCAINE  ANALGASIA. 


The  use  of  cocaine  analgsesia  in  operations  in  the  buccal 

cavity,  external  to  the  pharyngeal  isthmus,  . 87 

Caution  in  the  use  of  cocaine  analgsesia  in  the  nasal  and 

buccal  cavities,  .......  91 

Cocainization  in  the  excision  of  carbuncles,  ....  94 

Cocainization  in  the  ligation  of  the  vessels  in  the  triangles  of 

the  neck,  .........  97 

The  use  of  cocaine  in  superficial  neoplasms,  ...  98 

Obstacles  met  with  in  performing  a tracheotomy,  . . 99 

Value  of  cocainization  in  tracheotomies,  ....  106 

Cocainization  in  the  treatment  ot  an  abscess  in  the  trachea,  107 

Cocainization  in  the  excision  of  an  imbedded  popliteal 

tumor,  .........  no 

Cocainization  in  major  amputations,  ....  no 

Advantages  secured  by  the  use  of  cocaine,  . . . m 

Coca  nization  in  finger  and  toe  operations,  . . . 112 

Cocainization  in  the  removal  of  bursae,  . . . - 113 

Technique  in  the  treatment  of  bursa,  . . . . 115 

Observations,  . . . . . . . . 117 

Cocainization  on  the  thoracic  appendages,  . . . 120 

Thoracic  operations,  . . . . . . • 121 

Abdominal  subdistricts  wherein  cocaine  analgaesics  may  be 

employed,  . . . . . . • • 126 

Enumerations  of  the  pathological  conditions  in  which  co 
cainization  may  be  utilized,  with  advantage,  from 
above  downwards,  . . . . . . . 127 

Genito-urinary  operations,  ......  127 

Colotomy,  .........  128 

Rectal  cancer,  ........  129 

Cocainixation  in  strangulated  hernia,  . . - . 133 

Statistics  on  hernial  operations,  .....  135 


INDEX.  183 

Danger  from  pulmonary  anaesthetics  in  operations  for 

strangulated  hernia,  . ' . . . . . 136 

Classes  of  Operations  for  strangulated  hernia,  . . . 138 

Incomplete  operation  for  hernia,  .....  139 

Complete  operation  for  hernia,  .....  140 

Resume  of  cases,  . . . . . . . . 141 

Comments  on  cocainization  in  strangulation  cases,  . . 154 

General  classes  into  which  lesions  may  be  divided  wherein 

cocaine  may  be  employed  in  genito  urinary  surgery,  . 157 

Cocaine  in  minor  gynsecological  operations,  . . . 160 

Cocainization  in  the  treatment  of  haemorrhoids,  . . 162 

Technique  for  efficient  local  analgaesia  for  ano  rectal  opera- 
tions, .........  164 

Cocainization  in  delegating  the  femoral  artery,  etc.,  . . 168 

Cocainization  in  toe  amputations,  .....  169 

Cocainization  in  the  avulsion  of  an  in  grawn  toe  nail,  . i 69 

On  the  technique  of  cocainization,  .....  173 


BIBLIOG-RAPHY. 


Roller,  Carl — Cocaine  Anaesthesia. 

Corning,  Dr.  L. — Action  of  Cocaine. 

Juillard,  L. — Lecon’s  Chirurgicales. 

Watson,  B.  A. — Experimental  Studies. 

Wood’s  Therapeutics. 

Bartholow’s  Therapeutics. 

Price,  Dr.  Jos. — (In  Conversation). 

Reclus,  Paul. 

Keys’  Genito-Urinary  Diseases. 

Waterman,  Dr.  Sigismund — Studies  on  the  Blood  by 
Spectroscopic  Analysis. 

Knapp,  Herman — Cocaine  Anaesthesia. 

Abbe,  R.  — Cocainization  in  Dupuytren’s  Contracture. 
Discussion  at  New  York  Academy  of  Medicine. 


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